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iERICA. 



. 



Differential Diagnosis 



A MANUAL OF THE 



COMPARATIVE SEMEIOLOGY 



MORE IMPORTANT DISEASES. 

/ 

By F. de HAVILLAND HALL, M. D., 

ASSISTANT PHYSICIAN TO THE WESTMINSTER HOSPITAL, LONDON. 






AMERICAN EDITION. 

WITH EXTBXSIVB ADDITIOX^. 



JNoJHkbk 



PHILADELPHIA : 

D. G. BRINTON, 115 SOUTH SEVENTH ST 
1879. 



■ 



Entered according to Act of Congress, in the year 1878, by 

D. G. BR INTO N, 

in the Office of the Librarian of Congress, in Washington, D. C. 

All rights reserved. 



'ROM THE PRESS OF THH 

INQUIRER P. & P- CO., 

LANCASTER, PA. 



. 



NOTE OF THE AMERICAN EDITOR. 



The present work was at first designed to be little more than a 
republication of Dr. F. De Havilland Hall's Synopsis of the Diseases of 
the Larynx, Lungs, and Heart ; but as the advantages of the tabular 
method of presenting diagnostic points became more manifest to the 
editor, he concluded it would be a good service to many members of 
the profession, and many preparing to become members, to extend 
the plan to all the more frequent and important diseases. In carry- 
ing this out, he has held especially in view (i) the ear/y and often 
overlooked signs of the presence of disease ; (2) the collection of 
whatever symptoms are alleged on good authority to be pathogno- 
monic of pathological conditions ; (3) any peculiar features which 
diseases have been found to present in this country. Preference has 
been given to American over European authorities, as every year 
adds confirmation to the opinion, now widely received, that diseased 
conditions assume very different aspects under different climatic and 
sociological surroundings. 



CONTENTS 



PAGE. 

Introductory 17 



PART I. 
GENERAL DISEASES. 



CHAPTER I. 

THE FEVERS. 

The Febrile State 19 

Inflammatory, or Symptomatic and Essential Fever 23 

The Exanthematous or Eruptive Fevers 25 

Typhoid and Typhus Fevers -? 2 

Typhoid and Malarial Fevers -?g 

The Typhoid State 4! 

Malarial Fevers 43 

Cerebro-Spinal Meningitis 47 

Acute Tubercular Meningitis e 2 

Yellow Fever c-? 

Relapsing Fever 56 

CHAPTER II. 

DISEASES OF THE BLOOD. 

The Dyscrasise r rg 

The Arthritic, Dartrous, or Rheumic Dyscrasia 60 

The Scrofulous, or Strumous Dyscrasia 6 r 

(vii) 



Vlll CONTENTS. 

PAGE. 

The Syphilitic Dyscrasia 63 

The Tuberculous Dyscrasia 64 

Rheumatism 65 

Chronic Rheumatism 66 

Gout 69 

Rheumatic Arthritis 70 

Pernicious Anaemia and Leukemia 71 



PART II. 
LOCAL DISEASES. 

CHAPTER I. 
DISEASES OF THE NERVOUS SYSTEM. 

Cerebral Congestion and Cerebral Hyperaemia 73 

Cerebral Hemorrhage, Cerebral Thrombosis and Cerebral Embolism Compared. ... 75 

Cerebro-Spinal Diseases 76 

Comparative Table of Locomotor Ataxia, Multilocular Sclerosis, Disseminated 

Syphilosis and General Paralysis 76 

The Location of Cerebro-Spinal Lesions 78 

The Forms of Paralysis ; Organic, Functional, Hysterical 79 

With and without Tremors 82 

Sclerosis of the Cord 83 

Antero-lateral and Posterior Sclerosis 83 

Paralysis Agitans 85 

Reflex Paraplegia and Paraplegia from Myelitis 86 

General Paralysis of the Insane 88 

Syphilitic General Paralysis 92 

Pseudohypertrophic Paralysis 93 

Paralysis from Lead Poisoning 94 

Neuralgia 94 



CONTENTS. IX 

PAGE. 

Comparison with Myalgia 95 

With Spinal Irritation 96 

With Cerebral Abscess 96 

Spinal Irritation 97 

Hysteria 98 

Epilepsy ' 99 

Hysterical Paralysis 99 

Insanity . 101 

Mania and Melancholia Compared 101 

CHAPTER II. 

DISEASES QF THE RESPIRATORY SYSTEM. 

Symptoms of Laryngeal Diseases 104 

Diagnostic table of Acute Laryngitis 106 

Chronic Laryngitis 106 

Syphilitic Laryngitis 107 

Tubercular Laryngitis 107 

Perichondritis 108 

Benign Growths 108 

Malignant Growths 109 

Neuroses of the Larynx 109 

Croup and Diphtheria no 

Spasmodic Croup 1 10 

Inflammatory Croup I IO 

Membranous Croup in 

Diphtheria m 

Tonsillitis, Catarrhal and Parenchymatous 112 

The Regions of the Chest H-3 

Normal Differences between the two Sides of the Chest 1 14 

Methods of Physical Examination nr 

Normal Respiratory Sounds 116 

Normal Voice Sounds 116 

Abnormal Percussion Sounds 117 

Abnormal Respiratory Sounds ' 1 18 

Abnormal Voice Sounds f o, 



X CONTENTS. 

PAGE. 

General Rules for Diagnosis 122 

The Forms of Phthisis (Catarrhal, Fibroid, Tubercular) 123 

The Diagnosis of Incipient Phthisis 126 

Diagnosis between Incipient Phthisis and Bronchitis 128 

Clinical History of Phthisis 129 

Acute Phthisis 130 

Syphilitic Phthisis 132 

Bronchitis, Acute and Chronic 132 

Capillary Bronchitis compared with Pneumonia 134 

Pneumonia and Pleurisy 135 

Pleurisy with Effusion and Pneumonia with Consolidation Compared 139 

Diagnosis between Pneumonia and Pulmonary Apoplexy 140 

Pulmonary Embolism , . . . ' 140 

Asthma 141 

Pneumo-thorax and Pneumo-hydrothorax 141 

Emphysema, Vesicular and Interlobular 143 

Cancer of the Lung 145 

CHAPTER III. 

DISEASES OF THE CIRCULATORY SYSTEM. 

The Precordial Regions j^y 

Normal Sounds and Impulse of Heart •. i^g 

Endocardial Murmurs i$ a 

General Rules for the Diagnosis of Heart Disease 1^1 

Constitutional Symptoms of Heart Disease r ^ 2 

Clubbing of the Fingers l ^ 2 

Differential Signs Between Anaemic and Organic Blood Murmurs 153 

Pain at and near the Heart r ^ 

Aphorisms Regarding Angina Pectoris ^4 

Differential Signs of Aortic Obstruction and Aortic Incompetency t cr 

Differential Signs Between Mitral Obstruction and Mitral Incompetency 157 

Differential Signs Between Pulmonary Obstruction and Tricuspid Regurgitation. . . . 158 

Pericarditis 159 

Diagnosis Between Acute Endocardial and Exocardial Sounds 160 

Differential Signs of Cardiac Dilatation and Pericarditis with Effusion 161 



CONTENTS. XI 

PAGE 

Differential Signs of Simple Hypertrophy, Hypertrophy with Dilatation, and Simple 

Dilatation . 162 

Fatty Degeneraton of the Heart 162 

CHAPTER IV. 

DISEASES OF THE DIGESTIVE SYSTEM. 

Principal Symptoms 165 

The Tongue , . . . 1 65 

The Appetite 167 

Acidity (1) from Fermentation. (2) from Hyper-Secretion 167 

Pain 168 

Flatulence and Eructation 169 

Vertigo ( I ) Stomachal, (2) Cerebral 1 70 

Vomiting (r) Stomachal, (2) Cerebral 170 

Comparison of Atonic Dyspepsia, Chronic Gastritis, Gastric Ulcer and Gastric Cancer 173 

Indigestion or Dyspepsia 176 

Abdominal Phthisis 177 

Obstruction of the Bowels, Enteritis and Colitis 177 

Method of Examination 180 

Significance of Pain in the Liver 181 

Significance of Jaundice 182 

Jaundice with Obstruction 183 

Jaundice without Obstruction 183 

Diseases Characterized by Enlargement with Smooth Surface 184 

Enlargement with Uneven Surface 185 

With Diminution of the Organ 1 86 

Hepatic Abscess 1 86 

Internal Parasites 186 

Tape-worm 188 

Hydatids 188 

Round Worms 188 

Thread Worms 188 

Trichinosis 189 



Xll CONTENTS. 

CHAPTER V. 

DISEASES OF THE URINARY SYSTEM. 

PAGE. 

The Early Signs of Bright's Disease 191 

Comparative Diagnosis of the Different Forms of Bright's Disease (Acute Parenchy- 
matous Nephritis, Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Con- 
traction of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albuminoid or 

Angloid Renal Degeneration, Parenchymatous Renal Degeneration) 194 

Diabetes Mellitus and Glycosuria 196 

Diabetes Insipidus and Hydruria 198 

Urinary Calculi 199 



INTRODUCTORY. 



The nomenclature of diseases adopted by the best authorities 
divides them into two great classes — General Diseases and Local 
Diseases. General diseases are stated to comprehend those which 
pervade the whole system, and in which any local affection may be 
regarded as accidental; while local diseases are those which affect 
certain organs, and in which the involvement of any other part of the 
body is but a sequel of the local lesion. 

This classification is also the one most practically useful to the 
physician. The first question he should put to himself on examining 
a patient is, Have we here a general or a local disease? He reaches 
the answer by excluding those organs whose form and functions 
present nothing abnormal, and by distinguishing among such as are 
implicated those which indicate primary and essential lesions from 
those which are effected accidentally or secondarily. When no such 
primary lesions are discoverable, he has to do with a general disease. 

For the purpose of diagnosis, General Diseases are best divided 
into the two classes of (i) Fevers and (2) Diseases of the Blood. 
These, also, are each divisible into two classes marked by one or two 
leading and prominent symptoms, which are the guides to the diag- 
nostician. Thus, 

Fevers are either characterized by an eruption of a well-defined 
character (the Exanthemata); or by a recurrent marked diminution 
or total cessation of the symptoms (Periodic fevers); or else by a 
persistent course not manifesting either of these phenomena (Con- 
tinued fevers). 

Diseases of the Blood are either constitutional (the Dyscrasiae); or 
else characterized by definite local lesions (Rheumatism, Gout) ; or 

(17) 



1 8 INTRODUCTORY. 

by a recognizable change in the blood itself (Anaemia, Leukemia, 
Scurvy, Purpura). 

Local Diseases are more conveniently classified with reference to 
the physiological than the anatomatical divisions of the body. The 
functions of life are carried on by the Nervous, Respiratory, Cir- 
culatory, Digestive and Urinary systems, and the impairments of 
each of these form classes of diseases broadly discriminated by signs 
easy of recognition. The niceties of diagnosis are needed rather to 
distinguish between the varied diseases peculiar to each of these 
svstems than to locate the disturbance in one or the other of them. 



PAET I. 



GENERAL DISEASES. 



CHAPTER I. 



THE FEVERS. 

Contents. — The Febrile State. Inflammatory, or Symptomatic, and 
Essential Fever. The Exanthematons or Eruptive Fevers. Typhoid 
and Typhus Fevers. Typhoid and Malarial Fevers. The Typhoid 
State. Malarial Fevers. Cerebrospinal Meningitis. Acute Tuber- 
cular Meningitis. Yellow Fever. Relapsing Fever. 

THE FEBRILE STATE. 
The most common of all forms of disease is that which is pre- 
sented by the Febrile State. The chief objective symptoms which 
it offers are found in 

1. The pulse. 

2. The tongue and uvula. 

3. The temperature. 

4. The urine. 

(19; 



20 DIFFERENTIAL DIAGNOSIS. 

i. The pulse is increased in frequency, and may be either hard, full 
and tense, or small and contracted. The former condition is more 
common in active inflammations of the organs above the diaphragm; 
the latter, in many inflammations below the diaphragm and in idio- 
pathic fevers. In fevers of a typhoid form, an unusually slow pulse 
is sometimes encountered, as also a pulse with a double beat, the 
" dicrotic" pulse. 

2. The tongue in the beginning of the febrile state is usually whiter 
and dryer than usual, and more or less coated with a " fur" or viscid 
covering, from the more rapid evaporation of the watery secretions. 
Later on, in the progress of severe fever, the tongue becomes dry, 
and the exsiccated mucus forms a brownish or blackish crust, while 
the papillae shrink, so that on this crust becoming detached, the sur- 
face of the organ looks glazed and smoothed. The peculiar appear- 
ance of the tongue in certain diseases will be described in connection 
with these diseases. 

3. The temperature is one of the most prominent phenomena in fever ; 
yet its correct appreciation was never understood previous to the 
labors of Wunderlich, whose decease is so recent. The clinical 
thermometer is now as indispensable to the practitioner as the lancet 
used to be. 

In using the clinical thermometer, Dr. Sydney Ringer, of London, 
lays down that in order to insure correctness in the observations, the 
following conditions must be fulfilled : 

1st. That the patient should be in bed, otherwise the temperature 
of the surface will be much below that of the internal organs. 

2d. That the patient be in bed at least one hour before the obser- 
vations are made, since that time is necessary for the surface of the 
body to regain the heat lost by previous exposure. 

3d. The position of the person examined should be such that the 
anterior and posterior edges of the axilla are relaxed, for otherwise 
a cup-shaped cavity is formed, in which the thermometer moves 
freely, without being in contact with its walls. This occurs espe- 
cially in emaciated persons. 

4th. The temperature should be taken twice daily, say at eight in 
the morning and eight in the evening. If but one observation is pos- 



FEVERS. 2 1 

sible, then the evening should be preferred, since the morning tem- 
perature, abnormal though it may be, rises in the evening. 

5th. The thermometer should remain in the axilla at least five 
minutes. 

According to a series of observations by Dr. H. Wegscheider* 
the following propositions should be received in reference to the dis- 
tribution of temperature in febrile diseases : 

1st. There is no constant relation between the internal tempera- 
ture, as measured in the axilla, with the general temperature of the 
surface. 

2d. Two completely symmetrical parts of the skin, as between the 
toes, show no proportionate course in their temperature ; not only do 
they differ by not rising or falling to the same level, but one may rise 
while the other remains stationary or falls, and vice versa. 

3d. There is greater variation in the temperature-curves in the 
same part of the skin in the same person in fever than in health ; but 
in fever there is a striking fall of temperature, notably lower than in 
the healthy state. However, in those people who suffer from cold 
feet, the temperature is often as low, or somewhat lower. 

4th. It follows, from the last, that there is a greater difference in 
fever between the temperature of the axilla and that of the periphery 
than any changes of local temperature which may occur in health. 

There is a pretty constant increase and decrease of temperature in 
the specific fevers, a close observation of which, in accordance with 
the foregoing rules, will often serve as a valuable aid both in diag- 
nosis and in prognosis. Dr. Wunderlich, in his work, gives useful 
tables for this purpose, and we subjoin a valuable comparative table 
of the pulse as well as the temperature in seven of the more frequent 
febrile diseases, drawn from recent English observations. 

*Archiv der Palhologie, Feb., 1 877. 



22 



DIFFERENTIAL DIAGNOSIS. 



COMPARATIVE TABLE OF THE TEMPERATURE AND PULSE IN THE 
LEADING FEBRILE DISEASES. 



Day. 


Typhus 
Fever. 


Typhoid 
Fever. 


Measles. 


Scarlet 
Fever. 


Febricula. 


Rheuma- 
tic Fever. 


Pneumo- 
nia. 




T. P. 


T. P. 


T. P. 


1 T. P. 


T. P. 


T. P. 


T. P. 


ISt... 


























102.8 


123 


2d.... 






102. 


98 






104.2 


144 


103. 


99 






102.3 


120 


3 d.... 


104.8 


108 


103. 1 


98 






104. 


148 


I03-7 


103 






103.6 


122 


4th.. . 


103.6 


113 


103.4 


no 


102.3 


130 


103. 


134 


104. 


105 


101.8 


105 


104. 


126 


5 th... 


103. 


114 


102.7 


107 


103. 


124 


101.2 


122 


102.6 


99 


102. 


114 


103. 


122 


6th... 


103.2 


122 


103.2 


104 


100.2 


112 


100.6 


108 


98.4 


99 


102. 


116 


102.8 


122 


7th.. . 


104.2 


124 


103.7 


107 


98. 


102 


100. 


106 






103. 


120 


.100. 


114 


8th... 


103.8 


122 


102.5 


108 


98. 


98 


100. 


no 






100. 


90 


99- 


94 


9th. . . 


103. 


113 


103. 


108 


98. 


80 


99.8 


108 






100. 


96 


98. 


78 


ioth... 


102.7 


117 


102.6 


in 






99- 


100 






99-4 


86 






nth... 


102.4 


119 


103. 


in 






98.6 


104 






IOI. 


104 






1 2th.. . 


102.2 


10$ 


102.5 


112 






98. 


84 






IOI. 


102 






13th... 


100.5 


106 


102.2 


108 














102. 


100 






14th.. . 


100. 


100 


102.4 


109 














100.9 


100 






15th... 


99-4 


98 


101.8 


107 














100. 


88 






16th... 


98.7 


92 


102. 


100 














98. 


90 






17th.. . 


98.4 


90 


101.4 


100 














99. 


94 






1 8th... 


98.2 


85 


98.8 


98 














102. 


96 






19th.. . 






101.4 


105 






* 








103. 


102 






20th.. . 






102.2 


100 














101.6 


100 






2ISt 






98.8 


98 














101.7 


104 







The above table, prepared from a series of observations, by Dr. J. 
S. Warter,* illustrates the normal and average contrasts of pulse 
and temperature in the course of the diseases specified, when their 
tendency is to recovery. 

4. The urine in fever is scanty and high colored. Its alteration from 
the healthy average is chiefly in the much larger quantity of urea it 
contains. According to the researches of Dr. J. Burdon Sanderson, 
in the early stage of fever a patients excretes about three times as 
much urea as he would do on the same diet if he were in health, the 
difference between the fevered and the healthy body consisting chiefly 
in this, that whereas the former discharges a quantity of nitrogen equal 
to that taken in, the latter wastes the store of nitrogen contained in its 
own juices. That this disorder of nutrition is an essential constituent 
of the febrile process is indicated by the fact that it not only accom- 
panies the other phenomena of fever during their whole course, but 



* St. Bartholomew's Hospital Reports, vol. ii., p. 78. 



FEVERS. 23 

precedes the earliest symptoms and follows the latest. That it antici- 
pates the beginning of fever was first demonstrated by Dr. Sidney 
Ringer in his investigation of the relation between temperature and 
the discharge of urea in ague. That the same condition continues 
after the crisis has passed, i. e., the temperature has begun to sink, 
was shown by Dr. Squarey. 

There are various methods of determining the secretion and 
amount of urea. Its presence may be recognized when the urine 
has a deep yellow color, a high specific gravity, and a strong urin- 
ous odor. If a small quantity of it is allowed to evaporate to a 
mucilaginous consistence, and then nitric acid be added drop by 
drop, crystals of nitrate of urea are found. They are of a pearly 
white lustre, and their number indicates the quantity of the sub- 
stance present. When very abundant, the crystals will form on the 
addition of nitric acid to the urine without the preliminary evapora- 
tion. 

INFLAMMATORY, OR SYMPTOMATIC, AND ESSENTIAL FEVER. 

The group of symptoms collectively known as a fever often ac- 
companies strictly local maladies and injuries. In such cases it is 
distinguished as Inflammatory, or Symptomatic, Fever, and it is of 
the first importance to distinguish it from Esssential, or Idiopathic, 
Fever, under which general term all true fevers are included. The 
development of this distinction has been one of the most prominent 
achievements of the modern methods of diagnosis. It is astonishing, 
remarks a recent writer, with the progress of medicine, how many 
affections have been passed over from the domain of fevers to the 
narrower circle of inflammation of individual organs. Hence it is 
of prime importance to determine promptly in the beginning of a 
case whether the febrile symptoms are a feature of a local disease or 
the commencement of a general one. 

Dr. William Stokes* divides the local symptoms of essential 
fever into three groups: (1) Functional or nervous; (2) those de- 
pendent on special anatomical changes ; (3) those arising from re- 
active inflammation. 

* Lectures on Fever, London, 1874. 



24 



DIFFERENTIAL DIAGNOSIS. 



(i) Examples of functional symptoms are delirium, cough, diar- 
rhoea, epigastric tenderness, and the like ; (2) of the second group, the 
alterations which occur in the brain, lungs, spleen or intestinal glands ; 
(3) and of the third the swelling and infiltration of organs. What he 
calls " the grand rule of diagnosis" in fever is not to apply to these 
local symptoms in essential fever the rules of diagnosis of local diseases, 
as this would lead to a false appreciation of the disease, and to erro- 
neous treatment. For example, a typhus patient may exhibit the 
marked symptoms of inflammation of the brain ; but if he is treated 
with ice to the head and leeches, he forthwith sinks and dies. 



Inflammatory or Symptomatic Fever. 
Is usually preceded by some local 
lesions or symptoms. 

Pulse frequent, full and generally 
tense. 

Is accompanied by marked and 
definite local disturbance. 



Course is indefinite, dependent 
upon the progress of the local lesion. 



Anatomical lesions definite and in- 
variable. 



Essential or Idiopathic Fever. 
Has no definite antecedent local 
symptoms. 

Pulse frequent, full or small, but 
rarely tense. (Da Costa.) 

Local disturbances vary, and are 
not prominent, or but temporarily 
so. 

Runs a definite course, with a strong 
tendency to spontaneous termination 
at a given time. 

Generally characterized by absence 
of definite anatomical lesions. 



Of hardly less importance is the distinction between organic and 
functional (or neurotic) changes in fevers. Delirium, pain, coma, 
convulsions, cough, etc., may all appear as phenomena of the evolution 
of the poison which produces a general fever, without signifying any 
definite anatomical lesion. In other words, essential fever produces 
local symptoms without organic change. It is, remarks the author 
just quoted, because this proposition has not been sufficiently accepted, 
sufficiently engraved upon the minds of medical men, that so much 
mischief has been done in the erroneous treatment of fever. 



FEVERS. 25 

THE EXANTHEMATOUS, OR ERUPTIVE FEVERS. 

This group includes small-pox, scarlet fever, and measles, and also 
those more indefinite forms, varioloid, varicella, and rotheln. They 
have many points of similarity. "They are all characterized by a 
period of incubation, during which the poison lies dormant in the 
system; by a fever of more or less intensity preceding the eruption; 
by an eruption which presents a distinct aspect in each disease, and 
which pursues a definite, clearly defined course until it, and with it 
the febrile malady, disappears. Moreover, they are all very prone to 
occasion serious sequelae; are all, in the main, disorders of childhood; 
rarely attack the same person twice ; are contagious, and have not as 
yet been brought under specific treatment." (Da Costa.) 

It is of great credit to the practitioner, and often of the utmost 
utility to others, for him to make an early diagnosis between these 
diseases. This is not always possible to accomplish. But a close 
observer will find several indications which will guide him to a cor- 
rect opinion before the appearance of the rash. One of the principal 
of these is 

The condition of the throat. This region is affected at a very early 
stage in nearly all cases. In simple scarlatina the very earliest symp- 
tom is a more or less uniform redness of the middle of the soft palate, 
the uvula alone, or the uvula, anterior pillars of the fauces, and ton- 
sils; never the posterior wall of the pharynx alone. On the other 
hand, in small -pox, the part first affected is the posterior wall of the 
pharynx ; while in measles the posterior walls of the fauces and neigh- 
boring parts of the pharynx are always redder than the anterior pillars 
and soft palate (Dr. Alois Monti). In rotheln and measles the ton- 
sils are red and swollen early in the disease ; but in simple scarlet 
fever for the first twelve hours, there is very little swelling of the 
affected parts, and children seldom complain of pain in the neck or 
in swallowing. After twelve or twenty-four hours, the swelling com- 
mences, and the redness becomes less uniform, and more punctiform. 
This peculiar punctiform appearance may be noted often ten or twelve 
hours before the rash on the skin is visible. 

In malignant scarlatinal sore throat, there is from the first paren- 



26 DIFFERENTIAL DIAGNOSIS. 

chymatous inflammation of the tonsils and neighboring connective 
tissue. When this condition is associated with well-marked nervous 
symptoms, a severe case with ulceration of the fauces may be confi- 
dently predicted. 

In general terms, it may be said that when the soft palate has a dif- 
fused red hue, "similar," as Trousseau remarks, "to, but deeper than, 
that of the skin," while the tonsils are not involved ; when with this 
is a very hot skin; a very quick pulse; vomiting; a tongue with thick 
creamy fur, red borders, and prominent papulae; and with these symp- 
toms, exposure to the presence of a scarlatinal epidemic, the physician 
need not hesitate in pronouncing it scarlet fever. 

A very early symptom of scarlet fever has been insisted upon as 
strictly pathognomonic by an Irish physician, Dr. Joseph Duggan.* 
It is that the eye assumes a peculiar brilliant and glistening stare, 
very different from the liquid, tender, watery eye of measles, and 
which, once carefully noted, remains impressed on the observer's 
memory. 

The character of the preliminary fever often differs. In scarlatina 
it is marked and high, which distinguishes it broadly from diphtheria 
which is apyretic at the outset ; in measles it is of a catarrhal form ; 
while in small-pox it is associated with often severe pain in the back 
and loins, not observed in the other exanthemata. This spine-ache 
is central in its position, and is less affected by change of posture 
than is the pain of lumbago, and is not confined to one side nor to the 
erector spinas masses. It is stated by some authors that this pain is 
increased in proportion to the severity of the attack, and thus forms 
an important element in the prognosis ; but this statement should be 
confined in its application to adults, as in children the rachialgia is less 
intense. Dr. Wilks observes that the most virulent cases of variola 
are almost apyretic and devoid of feverish symptoms. 

In all the exanthemata, the eruption makes its appearance in the 
roof of the mouth, from twelve to twenty-four hours, and, in many 
instances longer, before it appears on the cutaneous surface. In 
small pox } in scarlet fever, in measles — in all their grades — the erup- 

* Medical Press and Circttla?', Feb., 1869. 



FEVERS. 27 

tion may be looked for, with confidence, in this region long before it 
can be detected at any other point, and, as the eruption is often the 
last link in the chain of evidence necessary to decide a question of 
diagnosis, the knowledge of this fact will often relieve both physician 
and patient. 

The eruption may, in small pox, often be felt before it can be seen. 
The sensation imparted to the finger is as if there were little shot 
underneath the skin. Its first appearance is as a simple red point or 
pimple, soon changing to a papule. The red blush of scarlatina dis- 
appears on pressure, but is immediately restored when the pressure 
is removed. It has not the least prominence to sight or feeling. 

Dr. Osler, of Montreal, has called attention to and described a 
number of initial rashes, which precede > by twelve to twenty-four 
hours, the appearance of the variolous eruption. They are princi- 
pally noticeable on the upper part of the trunk, and generally have 
the similitude of a deep, suffused flush. 

The pulse in variola is asserted, by some, to be pathognomonic,, 
and significant so early in the disease that the malady can be posi- 
tively diagnosed many hours before the eruption appears. But no 
definite descriptions nor tracings of this pulse have been given.* 

Having thus defined the special indications for a diagnosis of these 
diseases in their earliest stage, we give in the following table a synop- 
sis of their comparative history: 

-See Dr. A. S. Payne, Va. Med. Monthly, March, 1878; J. S. Conrad, Trans, of the 
Med. and Chirurg. Faculty of Md., 1874. 



28 



DIFFERENTIAL DIAGNOSIS. 



ROTHELN. 



SCARLET FEVER. 



INCUBATION. 

Period of incubation from one to I Very uncertain; from a day to 
two weeks. | several weeks. 



INVASION. 



Languor; shiverings; nausea and 
vomiting; sore throat. 



Premonitory fever of short dura- 
tion; relieved by the eruption. 



Shiverings; nausea, rarely vomit- 
ing; sore throat, sneezing and dis- 
charge from the nose. 

Fever, with great heat of skin and 
very frequent pulse ; not relieved by 
the eruption. 



ERUPTION. 



Appears early simultaneously over 
the whole body — is sadden and general 
— is less marked on the limbs than 
trunk. — Aitken, Roberts, Fox, Cop- 
land. 

May first appear upon the back, 
upon the chest or neck, upon the 
cheek or upon the forehead ; travels 
downward. — -J. L. Smith. 

At first like measles — minute dots, 
which rapidly assume the appearance 
of large, irregular shaped patches, 
varying from three-cent piece to 
twenty-five cent piece in size. 

These patches quickly become 
raised above the surrounding skin, 
especially toward the centre of the 
patch, and are of a darker red color 
at the centres. 

Fades in about four days ; without 
desquamation. 



On second day ; first on neck, and 
face and body ; spreads rapidly to 
limbs. 



The eruption is uniform or in very 
large patches of a scarlet hue, with 
interspersed raised spots and some 
vesicles; the rash is followed after 
the seventh day of its appearance by 
complete desquamation. 



FEVERS. 



2 9 



MEASLES. 

Generally from seven to 
days. 



SMALL-POX. 

INCUBATION. 

fourteen | Generally about ten days, but varies 
! from five to twenty days. 



INVASION. 



Lassitude, shivering, 
vomiting rare; sneezing, 
from nose; harsh cough. 



catarrrh ; 
discharge 



Fever, with hot skin and frequent 
pulse ; rather increased by the erup 
tion. 



Shivering, severe pain in the back; 
nausea. 



Fever often very violent, with 
bounding pulse and pain in the loins; 
great relief from occurrence of the 
eruption. 



ERUPTION. 

Appears on fourth day, first on | Eruption at end of third or on 
face, spreads gradually in forty-eight j fourth day ; first on lips, palate and 
hours to the rest of body. forehead. 



Comes out in small circular dots, 
like flea bites. These dots run to- 
gether and form blotches, of a rasp- 
berry color, and the latter are very 
prone to assume a crescentic or horse- 
shoe shape, being slightly elevated 
above surrounding skin. 

Eruption is sometimes diffused over 
the whole body in a confluent form, 
and "is of a dull, deep red color, 
offering a contrast to the crimson or 
scarlet redness of scarlet fever" — 
{Flint). 



Lasts five days; followed by 
complete desquamation. 



Eruption is first papular; after 
about a day becomes vesicular, then 
pustular; on the eighth clay of the 
eruption, the pustules maturate. 



in- 



30 



DIFFERENTIAL DIAGNOSIS. 



ROTHELN. 



SCARLET FEVER. 



ACCOMPANIMENTS. 



Sore throat ; hoarseness ; swelling 
of the neck; coryza. 

Cerebral symptoms absent. 



Sore throat ; coryza or bronchitis 
rare. 

Tongue red ; " raspberry" charac- 
ter. Cerebral symptoms frequent and 
grave. 



THERMOMETRY. 



"The temperature always highest 
on first day of attack, not exceeding 
102 °, next day falling to ioo°, and 
getting normal on the fifth day." 
(Fox.) 

"The temperature 
sub febrile (99.5 
times febrile (101 
( Wunderlich.) 



nearly always 
[00. 4 ) — some- 
to 102. 2 )." 



No secondary fever. 



Temperature may reach 105. 6°, or 
even a higher point. It usually re- 
mains continuously higher during the 
eruption, and it is thus "well distin- 
guished from those affections with 
which, on account of other symp- 
toms, it is most easily confounded, 
and more particularly measles and 
rotheln." (Wunderlich.) It begins 
to subside about the tenth day. 

No secondary fever. 



DESQUAMATION. 



Minute particles of cuticle, like 
scales of fine bran. 

Always begins toward centre of 
the eruptive patch, and gradually 
extends to the circumference. {Rob- 
erts, Aitken, Murchison.) 



Comes off in branny scales and in 
large patches. " Occasionally epi- 
dermis of the hands is detached en- 
tire, and may be slipped off like a 
glove. This is true also of the feet." 
{Flint J) 

Sometimes several successive des- 
quamations occur. 

Frequently accompanied with itch- 
ing, which in some cases is excessive. 



Pneumonia rare. 



COMPLICATIONS. 

Pneumonia rare ; pleurisy more fre- 
I quent. % 



SEQUELS. 



Dropsy rarely ; swelling and sup- 
puration of the cervical glands com- 
mon. (Paters on.) 



Bright's disease, dropsy, conjunc- 
tivitis, deafness, phthisis, chronic di- 
arrhoea, glandular enlargement. 



FEVERS. 



3* 



MEASLES. 

ACCOMPANIMENTS 

Bronchitis, coryza and redness of 
the eyes, very constant ; sore throat 
rare. 



Tongue coated, or red at edges. 



Cerebral symptoms, not severe. 



SMALL -POX. 



Sore throat and dry cough ; 
chitis rare. 



bron- 



Tongue coated and swollen, or red 
at edges. 

Cerebral symptoms, especially con- 
vulsions in children, frequent. 



THERMOMETRY. 



Temperature during the prelimi- 
nary fever may reach io5°-io6°. 
Within twelve to twenty-four hours 
from appearance of rash it sinks 
speedily to the normal. Protracted 
defervescence indicates a compli- 
cation. 

No secondary fever, though the 
fever may increase slightly before 
eruption leaves. 



Temperature during 
nary fever high, often 



the prelimi- 
106 ; falls 



rapidly to about ioo° after eruption. 
Rises again during the secondary fe- 
ver and falls slowly ; a slight rise dur- 
ing desiccation. 



Secondary fever well marked in all 
cases. 



DESQUAMATION. 

Always in branny scales, not in I In scabs, crusts and thick scales, 
patches or flakes. 



COMPLICATIONS. 
Pneumonia is very frequent, espe- 1 Pneumonia not very frequent, 
daily in adults. 



SEQUELAE. 



Chronic bronchitis, phthisis, con- 
junctivitis. 



Chronic diarrhoea, glandular en- 
largement, various diseases of the 
eyeballs and eyelids. 



32 DIFFERENTIAL DIAGNOSIS. 

TYPHOID AND TYPHUS FEVERS. 

Until within comparatively few years these two classes of fevers 
were confounded; and although now, in this country at least, they 
are distinctly recognized as wholly different diseased conditions, yet 
there are numerous instances where the clinical features of cases as- 
similate them to one or the other of these conditions, and yet fail to 
answer satisfactorily their currently received definitions. Such are 
the numerous gastric, nervous, simple continued, synochal, mixed, 
entero-miasmatic, typho-malarial, etc , types which are so often re- 
ferred to in medical literature. So true is this that a skillful physi- 
cian of Illinois writes : " I frankly acknowledge that I know but 
little, if anything, of the disease termed typhoid fever, as described 
by the majority of writers, European and American. I do not think 
I have seen a case in an active practice of over thirty years."* 

There are, in fact, wide variations in the local features of this group 
of diseases, and it is the exception to find the classical portraits of 
one of the group, drawn in the hospital wards of great cities, corres- 
pond at all precisely to the case as seen modified by the numerous 
special conditions of particular regions. We shall cite some of these 
modified types, after having considered the early symptoms and broad 
distinctions of typhoid and typhus. 

Typhoid fever is peculiarly a disease of slow and insidious ap- 
proach. For days, and sometimes for weeks, the patient is ailing; 
and as this gradual onset is known to the public, the physician is 
often called upon to pronounce an opinion as to the probability of 
the threatenings being of typhoid long before any positive sign is 
present. 

The general symptoms are a sense of weakness and fatigue, loss 
of appetite, muscular soreness, headache, generally dull, sometimes 
severe, disturbed sleep, poor appetite, low spirits. A characteristic 
and often early symptom is epistaxis. Frequently there is a bronch- 
itis, with shallow and rather frequent breathing, with some sonorous 
rales over the chest. A skilled auscultator can often pronounce from 
the character of the rale as to the presence of typhoid. They yield 

* Dr. R. G. Allen, Medical and Surgical Reporter, Vol. xxxii., p. 441* 



FEVERS. 33 

a peculiar, dry, ringing sound. In one of his clinical lectures, Dr. 
Da Costa remarks on this : " I should be loath to rest upon this 
symptom alone, but there is something about it that often makes the 
diagnosis of typhoid special and specific.''* 

The pathognomonic symptoms of typhoid are those connected 
with the abdomen. The belly is swollen and tympanitic ; there is 
diarrhoea with cutting abdominal pains ; rumbling and tenderness 
about the iliocecal valve and about the right iliac fossa. The 
tongue is tender, and sometimes moved with pain ; the teeth show 
accumulations of dried mucus (sordes) ; thirst is rarely excessive ; 
vomiting is rare; the mind is dull, and the delirium is usually low 
and muttering. The peculiar eruption appears on the chest and belly, 
most frequent between the nipple and navel, about the sixth or eighth 
day of the fever. It is in scattered small reddish spots, resembling 
flea-bites. Later they become rosier, and increase in area to the size 
of a finger nail. They are not elevated above the skin, and disappear 
entirely on firm pressure, but promptly re-appear. They give no 
feeling of hardness to the finger passed over them. These spots are, 
however, often wholly absent; and their presence, number and size 
do not seem to bear any relation to the severity of the attack. 

The prodromal symptoms above mentioned are, however, often 
varied. Dr. A. Larrabee, of Louisville, remarks that the character- 
istics of the prodromal stage, the lassitude, epistaxis, and even the 
susceptibility of the bowels to purgatives, which are valuable aids to 
early diagnosis in more northern latitudes, are not so important in 
the malarial regions of the southern and south-western United 
States;! and Dr. Jurgensen, of Kiel, Prussia, has given the history 
of a number of cases, with the anatomical characteristics of typhoid 
fever, when the attacks were sudden, with a well-marked chill, a high 
temperature (104 Fah.) and quick pulse, swelling of spleen and little 
or no diarrhoea, j 

In typhus the eruption usually appears as small discrete spots, 
slightly elevated, of a dingy red color and fading on pressure. In a 

* Medical and Surgical Reporter, Vol. xxvih., p. 1 1. 
f Trans. Kentucky State Med. Soc, 1876, p. 123. 
% Med. Times and Gazette, 1874. 



34 DIFFERENTIAL DIAGNOSIS. 

short time the spots cease to be elevated, and fade less completely on 
pressure, and a purple mottling appears in the interjacent portions of 
skin. At a still later period — say on the eighth, ninth or tenth day 
— the spots become entirely petechial, not being at all affected by 
pressure. The eruption begins to fade about the ninth or tenth day, 
and disappears about the fourteenth, and, if there be no local com- 
plication and the patient has not been very greatly prostrated, conva- 
lescence is established between that day and the twenty-first. In 
slighter cases, however, the serious illness may continue for only 
about a week, the eruption may never be very marked, and the 
patient may become convalescent from the tenth to the fourteenth 
day; while, in very severe cases, the rash may become petechial at 
an early period, and may continue on the skin till near the end of 
the third week, and the convalescence may be very greatly pro- 
tracted. Generally, in a simple uncomplicated case of typhus, the 
pulse and temperature fall below the normal standard at the earlier 
period of convalescence, and again rise when the patient takes more 
food and is capable of some little muscular exertion. Usually the 
bowels are confined during the course of the disease, but such is not 
always the case; sometimes towards the height of the fever and when 
there is great prostration of strength, the bowels are relaxed, 
apparently from want of power in the sphincter to retain the fecal 
matter; but in some cases there is profuse diarrhoea during the whole 
course of the disease, and this independently of any medicine. It is 
impossible to base the diagnosis between typhus and typhoid upon 
the confined state of the bowels in the former disease and the occur- 
rence of relaxation in the latter, for it is not uncommon for the bowels 
to be confined in typhoid. So, also, though, as a rule, the cerebral 
disturbance is more marked in cases of typhus than in typhoid, it 
sometimes happens that a patient will pass through a marked or even 
severe attack of typhus without much delirium, and retaining his 
intelligence to such an extent as to be able to answer simple ques- 
tions put to him without any apparent difficulty. In such cases, 
however, the patient, on recovery, has no recollection of anything 
that has occurred from a very early period of his illness till convales- 
cence is far advanced. 



FEVERS. 



35 



TYPHOID. 

Age generally from eighteen to 
thirty-five. 

Not contagious, or but feebly so ; 
often sporadic. 

Attack generally insidious. 



Duration fully three weeks ; often 
much longer. 

Death hardly ever before end of 
second week; more generally in or 
after third week. 



TYPHUS. 

At all ages, often in persons be- 
yond middle life. 

Highly contagious, generally epi- 
demic. 

Attack generally sudden ; no 
lengthened prodromata. 

Duration somewhat shorter ; often 
not prolonged beyond second week. 

Death not unfrequently at end of 
first week, and often before conclu- 
sion of second. 



Cerebral symptoms come on grad- 
ually ; last longer. 



Great emaciation. 



Delirium or decided stupor comes. 
on soon, sometimes almost from the 
onset; headache has appeared and 
disappeared by about the tenth day.. 

Less emaciation ; greater prostra- 
tion. 



Face pale, or flush confined to 
cheeks. 

Skin hot, sometimes covered with 
acid perspiration. 

Abdominal symptoms, such as di- 
arrhoea, tympanites ; intestinal hem- 
orrhage not unusual. 



Epistaxis common. 
Bronchitis and pleurisy. 



Eruption light red and not on ex- 
tremities. 



Face deeply flushed, of dusky hue, 
eye injected. 

Skin of pungent heat, sometimes 
emitting an ammoniacal odor. 

No abdominal symptoms; bowels 
constipated ; meteorism rare ; no in- 
testinal hemorrhage ; sometimes acute 
dysentery during convalescence. 

No epistaxis. 

Pneumonia, or marked congestion 
of the lungs, and bronchitis of finer 
tubes. 

Eruption darker color and all over 
the body. 



36 



DIFFERENTIAL DIAGNOSIS. 



Autopsy shows morbid state of Pey- 
er's patches ; enlargement of mesen- 
teric glands; ulceration of mucous 
coats of intestines; enlargement and 
softening of spleen ; ulceration of the 
pharynx. 



No constant post mortem appear- 
ances ; most common are dark- col- 
ored, liquid blood, and enlargement 
of the spleen ; softening of heart 
more common than in typhoid ; no 
intestinal lesions. 



COMPARATIVE THERMOMETRY (DR. J. W. MILLER). 

TYPHOID. TYPHUS. 



The duration of elevated tempera- 
ture is very rarely less than twenty- 
one days ; it is generally longer, and 
may be protracted to thirty-five days 
or even more. 

The evening temperature is almost 
constantly higher than that of the 
morning. 

The difference between the morn- 
ing and evening temperature is gener- 
ally, throughout the case, greater than 
in typhus; and towards the end of the 
fever there occurs the very character- 
istic oscillation of temperature, during 
which the difference is frequently five, 
six, or even seven degrees, and which 
may continue from a few days to a 
week or more. 

A high temperature is frequently 
accompanied by a pulse but slightly 
accelerated, and occasionally by a 
pulse slower than normal. 



The duration of elevated tempera- 
ture is very rarely beyond eighteen 
days ; it is generally shorter by sev- 
eral days, and may be even so short 
as nine days. 

The evening temperature is fre- 
quently lower than that of the morn- 
ing. 

The difference between the morn- 
ing and evening temperature, during 
the height of the fever, or from about 
the third to the tenth or eleventh day, 
is comparatively seldom above one 
degree, and although about the period 
of defervescence the difference is 
sometimes much greater ; the oscilla- 
tion is not continued over more than 
one or two days. 

A high temperature is, as a rule, 
accompanied by a high pulse. 



The varieties of fever called gastric and nervous have not been 
recognized as distinct types by the most recent writers. Yet there 
is no doubt that many cases of continuing fever present gastric 
rather than abdominal symptoms, and various other perceptible 
variants from the type of a mild typhoid. The following semeiolog- 
ical table, drawn from Dr. Copland's work, will illustrate this: 



FEVERS. 



SIMPLE CONTINUED 
FEVER. 
100-120, small, weak, irregular; 
intermittent when a dangerous 
attack. 

Heat of surface generally rises 
over ioo°. 

White, foul, loaded or furred ; 
again red at its sides, and point 
loaded with dirty yellow fur. 

Tenderness at epigastrium ; 
looseness or diarrhoea of an ochery 
hue; vomiting early. 



Pain in head, throbbing of 
arteries, brilliant expression of 
eyes, marked acuteness of senses, 
watchfulness and restlessness, 
moaning and incoherent mutter- 
ing, dilated pupils, and coma. 

A common and early complica- 
tion, either to bronchial surface or 
congestion of substance. 

Sore-throat or inflammation of 
fauces sometimes accompany. 



By subsidence of the prominent 
morbid actions indicative of a 
gradual decline. 



NERVOUS FEVER. 

Pulse. Soft, feeble, and quick ; about 

eleventh day very quick and un- 
equal. 

Temperature. Heat of skin natural and dimin- 

ished. 

Tongue. Loaded or covered with a dirty 

mucus, afterward brown or black, 
incrusted or fissured. 

Gastric Fetor of the breath and of the 

Symptoms. discharges, an irregular relaxed 

state of the bowels, pain at the 

epigastrium, nausea and vomiting. 

Symptoms. Countenance pallid or tran- 

siently flushed, head heavy, con- 
tinual restlessness, want of sleep, 
tremor, hearing dull, coma, un- 
conscious evacuations, low delir- 
ium, early stupor and delirium. 

Lung The bronchial surface is the 

Symptoms. part chiefly affected ; substance of 

the lungs sometimes complicated. 

Affection of Sore-throat, occasionally so se- 

Throat. vere as to resemble an attack of 

anginose maligna. 

Crisis. Often announced by a true 

crisis. 



Gastric fever is recognized by Niemeyer and other competent 
authorities as a separate type. It commences with loss of appetite, 
headache and languor followed by a slight chill, with marked gastric 
irritability, great nausea, frequent vomiting, and constipation. There 
is considerable tenderness on pressure over the stomach, a low pulse 
(60 to 70 per minute), and a temperature at first rising slightly (to 
ioo° Fah.), then falling below the normal as the disease advances (to 
95 and even 90 ). A grave symptom is double vision or total loss 
of vision. There are no tympanites, diarrhoea, delirium, subsultus 
tendinum, spots, iliac tenderness, nor sordes, as in typhoid. Women 
are more liable to it than men, old persons than those of middle age 
or youth. Its outbreaks indicate it to be a zymotic disease, and the 



38 DIFFERENTIAL DIAGNOSIS. 

mortality is even higher than in typhoid. The pathognomonic 
symptom of the disease is the peculiar sweetish odor of the breath ; 
it is likened by some to the odor arising from hot water poured on 
garlic, having a slightly alliaceous odor; or, according to others, it 
resembles a faint aroma of valerianic acid. * 

Typhlitis can readily be distinguished from typhoid fever by the 
pathognomonic sign of a dense tumor in the iliac fossa, increasing, 
and exceedingly tender on pressure. 

TYPHOID AND MALARIAL FEVERS. 

TYPHO-MALARIAM (Woodward), ENTERO-MIASMATIC (Wood), OR 
REMITTO-TYPHUS (Drake) FEVER. 

The experience of numerous observers has proven that there is a 
complex form of fever prevalent in malarious districts, in which the 
typhoid and miasmatic elements are combined. It has been pro- 
posed by Dr. J. J. Woodward to call this " typho-malarial fever," a 
term which he explains to be applied " not to a specific or distinct 
type of disease, but to the compound forms of fever which result 
from the combined influence of the causes of the malarious fevers 
and of typhoid fever." \ 

In order to bring into relief the broad distinctions between the ty- 
phoid and malarial fevers when in their typical forms, the following 
comparative table has been prepared by Dr. E. M. Hume : % 

TYPHOID. MALARIAL. 

Decomposing animal and veg- Cause. Emanations from marshes, 

etable matter. damp, low or new soil ; always 

vegetable, never animal. 

Old soil ; may be high and dry Locality. New land, moist, low and 

and long settled. swampy. 

Epidemic of typhoid fever. Circumstantial Prevalence of malarial disease. 

Evidence. 

*Dr. G. B. Bullard, Trans, of the Vt. Med. Soc, 1877, pp. 52-56. 
f Transactions of the International Medical Congress, 1 876, p. 340. 
\ Peninsular Journal of Medicine, Feb., 1875. 



FEVERS. 



39 



TYPHOID. 

Seldom after forty. 

Continued without intermission 
or remission. 

Lasts three or four weeks ; can- 
not be interrupted. 

Great nervous disturbance and 
prostration ; dull, heavy, throb- 
bing, persistent frontal headache; 
twitching of muscles ; tickling of 
throat ; ringing in ears ; deafness ; 
mind stupid. 

Asthenic, not wild. 

Frequent. 

Diffused bronchitis with tough, 
tenacious sputa. 

From 70 to 140 beats per min- 
ute, small, irregular or double. 

Hot, even when moist ; emits 
a peculiar, musty odor, pathog- 
nomonic of this fever. 

Indicates an increase of tem- 
perature from morning to even- 
ing of about 2 deg., and -a de- 
crease of I deg. from night to 
morning; commences first day 
98.5 deg., reaches its maximum 
of 104 deg. on the morning of 
the fourth day ; from this time 
the evening temperature ranges 
between 103 deg. and 104 deg., 
morning 1 deg. lower. 

Protrudes tremblingly ; is cov- 
ered with a whitish yellow coat, 
which disappears and is replaced 
by a dry, pale brown one, with 
red glazed tip and edges ; teeth 
covered with dark brown sordes. 



Pale, 
flushed. 



livid, muddy ; cheeks 



Age. 
Periodicity. 

Duration. 



Nervous impli- 
cation. 



Delirium. 

Epistaxis. 

Lungs. 

Pulse. 

Skin. 

Thermometer. 



Tongue. 

Complexion. 
Urine. 



MALARIAL. 

All ages. 

There is either intermission or 
remission. 

Can be interrupted and cured 
in a few days. 

None. 



Sthenic. 
None. 



all. 

More frequently high, full and 
bounding. 

Dry and hot, odor acid and 
swampy. 



Rises rapidly to 105 deg. or 
more first day or two, and falls 
suddenly; is not so uniform. 



sediment ; frequently contains al- 
bumen; has typhoid odor like 
body. 



Coated all over with a heavy, 
dark, yellow coat. No sordes. 



Sallow ; eyes yellow. 

Dark color, turbid, no albu- 
men. 



40 



DIFFERENTIAL DIAGNOSIS. 



TYPHOID. 

Diarrhoea, except in mildest 
cases ; stools offensive, pea soup, 
bright yellow or brown; devoid of 
mucus, but sometimes contains a 
whitish flocculi. 

Tympanitis occurs, giving tub 
shape to abdomen ; pressure over 
caecum produces pain and gurg- 
ling sound; tenderness over 
spleen. 

Stomach not involved ; no se- 
vere pain anywhere, except where 
peritonitis occurs. 

Occurs during second week ; 
from one to twenty small rose- 
colored pimples, size of pin head, 
appear on abdomen, chest or 
back ; do not extend to extrem- 
ities; present no distinct elevation 
to the touch, disappearing upon 
pressure, but reappearing upon 
its removal; lasts about three 
days; fade away and a fresh 
crop appears. This eruption is 
claimed to be " peculiarly and 
absolutely diagnostic of typhoid 
fever." Later in the disease su- 
damina appear. 



Excretions 
from Bowels. 



Abdomen- 
shape, etc. 



Pain. 



Eruption. 



MALARIAL. 

Bowels costive ; dark, 
dry, bilious stools. 



hard. 



No tympanitis or tenderness of 
abdomen. 



Gastric disturbance and vomit- 
ing of bile ; pain in stomach and 
elsewhere very intense. 

Eruptions of different kinds 
sometimes occur, but are so dif- 
ferent in shape, feel, duration, 
number, extent and place, that 
they need never be mistaken for 
the typhoid eruption. 



Great — averages 



one in nve. 



Mortality. 



Lesions. 



Very slight- 
in a hundred. 



-not one fatal case 



Hemorrhage from congestion 
of bowels rare ; congestion of 
stomach, lungs, liver and spleen, 
the two latter sometimes become 
enlarged. 



Inflammation and ulceration of 
Peyer's, solitary and Brunner's 
glands ; perforation of bowels 
with peritonitis, and fatal hem- 
orrhage; inflammation and en- 
largement of mesentery glands 
and the spleen (which sometimes 
burst) ; the brain, stomach, liver 
and lungs sometimes inflamed. 

We shall now consider the character of a disease presenting in 
its different stages symptoms both of malarial and typhoid fever. 
The name Remitto-Typhus was given it by Dr. D. Drake, who also 
spoke of it as "the typhoid stage of remittent or autumnal fever." 
He does not consider it a distinct disease, but a genuine hybrid of 
typhoid and remittent fevers. He remarks that in many cases the 
stage of invasion is nearly the same length in both ; both attack males 



FEVERS. 



4* 



more than females ; and that when remittent terminates fatally, sub- 
sultus tendinum, a dry tongue and intestinal hemorrhage are some- 
times present. He has, however, never seen a decided intermittent 
pass into typhoid ; nor well-marked typhoid terminate in an inter- 
mittent* 

Pending and since the war, typho-malarial fever has attracted much 
attention, and its traits have been thus distinguished against simple 
typhoid. 



TYPHOID. 
Occurs in all localities, most com- 
mon in the north. 

Invasion gradual and without re- 
mittence. 

Daily exacerbation and remission 
slight. 

Diarrhoea the rule. Tympanites 
common. Abdominal tenderness con- 
siderable ; epigastric and hepatic ten- 
derness slight. 

Temperature comparatively low. 
Delirium low and muttering. 

Spleen not involved. 

Sordes on the teeth the rule. 

Peyer's glands always involved. 

Rose-colored eruption present. 

Pigment deposits absent. 



TYPHO-MALARIAL. 
Only in miasmatic localities ; most 
common in the south. 

Often begins as simple intermittent 
or remittent. 

Decidedly marked. 

Constipation the rule. Tympanites 
rare. Abdominal tenderness slight; 
epigastric and hepatic tenderness con- 
siderable. 

Temperature high, especially at out- 
set. D^irium active. 

Tumefaction of spleen very marked. 

Sordes rare. 

Rarely involved. 

Generally entirely absent. 

Pigment deposits in various tissues 
and organs very common. 



THE TYPHOID STATE. 
It is a common error to confound the typhoid condition which 
occurs in many diseases with typhoid fever, properly so-called. This 
typhoid state may be developed in typhus and typhoid fever, in acute 

* Diseases of the Interior Valley of North America, p. 556. 



42 



DIFFERENTIAL DIAGNOSIS, 



pneumonia, rheumatism, tuberculosis, pyaemia and various renal dis- 
eases, especially the granular or gouty kidney, and Bright's disease. 
The exciting cause in all these cases, it is believed, is the accumula- 
tion in the blood of the products of disintegration of the nitrogenous 
tissues. 

The so-called "typhoid symptoms" are a quick, soft pulse; a dry, 
brown tongue; the symptoms and physical signs of hypostatic conges- 
tion of the lungs; impairment of the mental faculties; stupor passing 
into coma ; delirium, which is at one time acute and noisy, at another 
low and muttering, and not unfrequently associated with muscular 
tremor; involuntary evacuations. The skin is dusky, moist and often 
emitting a fetid odor. There is little thirst and often difficulty in 
swallowing. The temperature and urine vary considerably. The 
respirations are shallow and somewhat accelerated. The bowels are 
sometimes constipated, but often relaxed with offensive evacuations. 

The difference between this condition, as it supervenes in the above 
named diseases, and true typhoid, or continued fever, may be thus 
presented : 



THE TYPHOID STATE. 
Arises in the course of an antece- 
dent local disease 

Is always traceable to blood poison- 
ing from deficient elimination. 

These symptoms generally absent. 



May be a diffused rosiness from 
dilatation of superficial capillaries, 
but nothing like the taches rouges. 

Rare. 



Not usual, except in malarious 
cachexia. 

Urine may show albumen or pus. 



TYPHOID FEVER. 
Begins without any history of pre- 
ceding disease. 

Can often be traced to an external 
zymotic or septic influence. 

Diarrhoea, tympanites, epistaxis, 
tenderness over intestinal glands, 
pain in iliac fossae. 

Eruption of rose -colored spots. 



Intestinal hemorrhage not infre- 
quent. 

Enlargement of spleen very con- 
stant. 

Albumen and pus not present. 



FEVERS. 43 



MALARIAL FEVERS. 

The characteristic symptom of all malarial diseases is periodicity. 
It is not, however, pathognomonic; for hectic and syphilitic fevers, 
neuralgia and certain hysterical diseases, simulate this trait very 
closely. The diagnosis, however, in most instances is facile. 

Intermittent begins with a chill, cold extremities, pale face, chattering 
teeth and pulse feeble; followed by a decided fever, the face flushed, 
the skin hot, the pulse full and rapid ; and ends with a profuse per- 
spiration, soft, moderate pulse, and restoration of the secretions. This" 
recurs at definite intervals, with complete intermission between times. 

In Remittent fever we find the same development of the phenom- 
ena, the chill, the fever, the perspiration, but without complete abate- 
ment of the febrile symptoms in the interval. They continue, though 
lessened, and usually have daily exacerbations. 

Between these two most common forms there are the differences 
that in intermittent the patient is well between the paroxysms; in 
remittent he continues ailing : in intermittent a distinct chill precedes 
each attack ; in remittent the chill is slight or absent : in intermittent 
the appetite is good between the invasions ; in remittent nausea and 
anorexia are present. Dr. Daniel Drake says: "If we suppose an 
ague shake to be reduced to a mere chill, but the subsequent hot 
stage aggravated and prolonged, we shall form a just conception of 
the relations, in symptomatology, between intermittent and remittent 
fever." * * 

The more intense cases of malarial poisoning develop algid perni- 
cious or congestive chills, malignant remittent fever, and malarial liem- 
morhagic fever. 

In congestive chill the symptoms of an ordinary intermittent are 
present, but in an exaggerated form. The chill is intense, the skin 
and even the breath seem cold; the face is cadaveric; the respiration 
is sighing; the pulse scarcely distinguishable; the shivering shakes 
the bed. When the stage of fever comes on, the pulse is full and so 
quick that it can scarcely be counted ; the skin of the body is hot 

* Diseases of the Interior Valley of North America, p. 95. 



44 DIFFERENTIAL DIAGNOSIS. 

while the feet and hands are cold ; delirium is active ; thirst intense ; 
the stomach is irritable. The perspiration that follows brings no 
relief; the patient lies prostrate and sometimes unconscious. When 
the congestion affects the lung, there is a sense of smothering, difficult 
breathing, and bloody expectoration ; when it attacks the stomach 
and bowels there are violent spells of vomiting, foaming or soap-like 
white discharges, and great epigastric tenderness. In these cases the 
mind is usually clear ; but when it is the brain which is involved, there 
is intense headache, the mind is dull or delirious, and coma is apt to 
supervene. Patients rarely survive the third chill of this intensity. 

The diagnosis of malignant remittents has been carefully set forth 
by Dr. Daniel Drake as follows : 

1. The pulse does not rise in fullness and force during the exacer- 
bation, as in other forms of remittent fever, but is generally small, fre- 
quent, weak and variable. When the remission begins, it generally 
improves slightly, but to a much less extent than in mild remittents. 

2. The feeling of abdominal oppression, and the anxiety, restless- 
ness and gastric irritability, are deeper in this than in other forms of 
remittent fever ; and these symptoms never entirely cease during the 
remission. 

3. A coldness in the hands and feet, or of the ends of the toes and 
fingers only, continues through the hot stage, while the trunk of the 
body and the head are in high fever heat. With the arrival of the 
remission this coldness, in milder cases, is replaced by a natural tem- 
perature ; but in the more malignant it continues. Many experienced 
physicians regard this as the most characteristic sign of malignant 
remittent. 

4. There is no time when the fever is absent ; and whatever irrita- 
tions or congestions are formed in the cold stage, and whatever 
inflammations are set up in the hot stage, remain, though moderated 
in degree, throughout the remission* 

Hemorrhagic malarial fever commences with a chill of the conges- 
tive type ; and during the first paroxysms the symptoms which dis- 
tinguish this from all other fevers usually make their appearance. 

* Diseases of the Interior Valley of North America, p. 113. 






FEVERS. 45 

These are jaundiced skin, and vomiting, apparently without any effort, 
of a dark fluid; the faeces dark, offensive, and tawny looking; the 
color of the skin yellowish or bronzed, and the uri?ie colored with 
blood. The last mentioned is pathognomonic. Sometimes the urine 
is profuse, though mixed with blood, which is a favorable symptom. 
Most of such cases recover ; but when the urine grows scanty, and 
suppression ensues, the result is always fatal.* The remissions are 
irregular and often ill-defined ; and after the hot stage there is no per- 
spiration, f Pain in the back is severe and incessant ; the stomach is 
irritable, and the mental powers often obscured. 

The tongue presents in malarious diseases some peculiar appear- 
ances. One of these has been described as follows by Dr. Wm. A. 
Love, of Atlanta :J 

While the appearance of the tongue indicative of physiological and 
pathological conditions of the alimentary mucous membrane, presents 
itself on the upper papillated surface — the border and outer edges pre- 
sent the peculiarity indicative of malarial toxaemia. It consists in a 
peculiar pectiniforme appearance of the edges of the tongue, as though 
these edges had been under the pressure of the sides of the teeth of 
a comb — just as, in certain "languid and flabby" states of the primae 
viae, we find the edges presenting a crenated appearance, produced by 
the indentations resulting from the pressure of the teeth in the oral 
cavity — just within this pectiniforme edge, making the outer border of 
the upper surface, of greater or less width, in different cases ; or in dif- 
ferent degrees of malarial toxaemia, there appears a smooth margin, 
both the pecthiiforme edge and the smooth margin presenting a cleaner 
appearance and a brighter line than the other portions of the surface of 
the organ. 

A characteristic color of the tongue in malarial poisoning has been 
adverted to by Professor Charles O. Curtman, M. D., of St. Louis. 
He describes it as almost uniformly present. The color of the dor- 
sum of the tongue as far back as the circumvallate papillae is of a 
bluish gray tinge, somewhat resembling that of old sheet zinc or lead. 

*Dr. Greensville Dowell, Yellow Fever and Malarial Fever, p. 213. 

fDr. Thacker, Cinn. Med. Nezvs, 1872. 

\ Trans, of the Med. Association of Georgia, 1878. 



46 DIFFERENTIAL DIAGNOSIS. 

It occurs in various degrees of intensity, giving the impression of a 
coloring of greater or less thickness, superimposed upon the epithelial 
surface, sometimes quite thin and transparent, at other times almost 
opaque. In some cases this hue is observed without any other pro- 
nounced symptoms of malaria ; but in all such the distinct malarial 
symptoms follow. The disappearance of this color serves as a valua- 
ble index of the perfect restoration to health.* 

The symptoms of malarial poisoning are multiform, and are fre- 
quently so masked and disguised that the closest observation fails to 
detect their origin. This is the condition of malarial toxcemia.. It 
is broadly characterized by a tendency to cerebral, thoracic and ab- 
dominal congestion, obstinate to ordinary remedies, and often slightly 
periodic in exacerbations. Bronchitis, diarrhoea, simple fever, tooth- 
ache, neuralgia, ophthalmia, urticaria and other skin diseases, even 
hsemopystis, hysteria and rheumatism, may all be simulated by this 
subtle poison. 

Careful examination will sometimes disclose evidence of period- 
icity in an increase of suffering at regular periods; sometimes at 
intervals of several days, or even weeks, apart ; or they may be 
regularly aggravated at morning, noon or night. Sometimes subor- 
dinated to the prominent symptoms, and apt to be overlooked by 
the patient unless particular inquiry is made, are slight recurrent 
headaches, intolerance of light, shiverings, or a sense of cold, or al- 
ternating heat and cold, or perspirations. A trace of blood in the 
urine, especially in the tropics, is a common indication of malaria. 
Nausea or vomiting, or a copious watery discharge from the bowels 
at periodic intervals, are often observed, especially in children. f The 
skin is harsh, dry, and presents a muddy or else a greenish-yellow 
hue, which is most noticeable on the face, neck and arms. The 
appetite is capricious, the strength easily exhausted, the temper irri- 
table, the mind readily depressed, and the energies diminished. On 
careful percussion the spleen is nearly always found to be decidedly, 
and the liver slightly, larger than in health. 

*St. Louis Med. and Surg. Jotirnal, 1869. 

■j- See an article on Infantile Malarial Toxaemia, by Dr. Joel C. Hall, in the Medical 
and Surgical Reporter, Vol. xxxi., p. 147. 



FEVERS. 47 

The condition of the blood in malarial poisoning has been studied 
with definite results. Dr. A. Kelsch has found that the white cor- 
puscles diminish during an attack to one-half or one-third of their 
normal number, and continue less than usual so long as there is 
splenic enlargement.* The microscope also discloses granules of 
pigment matter floating in the blood. They are irregular angular 
masses, usually from one-half to one-fourth the size of the red cor- 
puscles, dark in color and easily recognized.! 

CEREBO-SPINAL MENINGITIS (SYN. EPIDEMIC MENIN- 
GITIS, SPOTTED FEVER). 

The onset of this disease is usually sudden, beginning with a 
severe chill, vomiting and intense headache, and an elevation of pulse 
and temperature. The pathognomonic symptom is that the head is 
drazvn backwards and downwards, and the muscles at the back of the 
neck are rigidly contracted. The pupils are also contracted. 

At an early period herpes appears on the face and limbs, the skin 
is hyperaesthetic, and the patient cannot bear handling. After about 
four days convulsions set in, tetanic contractions make their appear- 
ance, stupor follows, passing into a coma, preceding dissolution. The 
bowels are persistently constipated, and the urine passes involuntarily. 

In cases tending toward recovery, the acute symptoms subside after 
a week or two, and convalescence takes place, attended by headache 
and muscular contraction. 

In regard to differential diagnosis, it may be simulated by typhus 
or masked variola. The absence of tetanic spasms of the post-cervi- 
cal muscles in these diseases will aid in recognizing them. The pro- 
tracted cases, where this symptom is not prominent, may resemble 
typhoid fever. In both there is an eruption, some similar cerebral 
symptoms, and occasionally intercurrent diarrhoea. But the invasion 
of cerebro-spinal meningitis is more sudden, the headache more 
violent, and there is vomiting and constipation ; while later the spinal 
pain, the herpes, the tetanic spasms and the continued headache, are 
broad distinctions. 

* Archives de Physiologic, Oct., 1876. 

f For particulars see J. F. Meigs, Pa. Hospital Reports, Vol. I. 



48 



DIFFERENTIAL DIAGNOSIS. 



True tetanus is distinguished by the absence of epidemic preva- 
lence, by the clearness of the mental powers, and by the history of 
the case pointing to some injury. 

Certain forms of malignant malarial fever counterfeit cerebro-spinal 
meningitis, especially during convalescence, when the affection pre- 
sents periodical intermissions of the febrile state. The points of dif- 
ference may be summed up as follows (Hamilton) : 



CEREBRO-SPINAL MENINGITIS. 
Inceptive chill not marked. 

Disease epidemic, and chiefly 
among children. 



CONGESTIVE PERNICIOUS MA- 
LARIAL FEVER. 

Chill quite marked. 

Epidemic and common to all ages. 



Muscular spasms the rule. 

Bowels constipated. 

Pulse and temperature do not suf- 
fer rapid variations. 

Temperature does not undergo per- 
iodical changes. 

Face flushed; eruption before 
fourth day. 

Delirium and coma not affected by 
large doses of quinine. 

Increase of fibrine and rapid co- 
agulation of blood when drawn. 



Muscular spasms very rare. 

Not usually so. 

Both subject to great variations, 
feeble and irregular. 

Undergoes decided periodical 
changes. 

Complexion sallow; no eruption. 



All symptoms modified usually by 
large doses of quinine. 



In distinguishing it from other head affections it should be ob- 
served that, while pain in the head, vomiting, epileptiform attacks, 
disease of the optic discs, emaciation, eruptions, involuntary mictu- 
rition, are symptoms found in many of them, the sudden onset of 
symptoms, pain in the back of the neck, the stiffness of the muscles 
of the neck, and retraction of the head, are sufficient to separate cere- 
bro-spinal meningitis from hydrocephalus acquisitus, basilar meningitis, 



FEVERS. 



49 



and tumor of the brain, diseases to which, in its symptoms, it is nearly 
allied. 

It may also be noted that Dr. Hayden, of Dublin, a competent au- 
thority, states that he never saw a case of cerebro-spinal meningitis 
unattended by pains in the calves of the legs, and he should make a 
presumptive diagnosis from the presence of that symptom alone. 

Dr. Dowse, of London, has insisted on the importance of distin- 
guishing sporadic from epidemic cerebro-spinal meningitis. He main- 
tains that in its epidemic form the sensorium is more or less affected 
from the first, and that the membranes over the superior cerebral con- 
volutions, cerebellum, and posterior columns of the cord, including 
the nerve substance, are primarily, if not wholly, the seats of lesion. 
In the sporadic form, on the contrary, the sensorium and special 
senses are only slightly influenced, and the inflammation centres itself 
upon the meninges at the base of the brain and the anterior columns 
of the cord. He therefore gives to the latter affection the name of 
occipito, or basic cerebrospinal meningitis, in contradistinction to the 
former well-known disease. He draws his conclusions and diagnosis 
from signs and symptoms, as evidenced in the following table : — 



EPIDEMIC CEREBRO-SPINAL 

MENINGITIS. 
Attack sudden, without any special 
predisposing cause. 



SPORADIC OR BASIC CEREBRO- 
SPINAL MENINGITIS. 
Attack commences gradually and 
resembles an onset of acute rheuma- 
tism. 



Apparently of a contagious or in- 
fectious origin. 

Sensorium affected from the first. 



Usually arises from exposure to 
cold, exhaustion, and privation. 

Sensorium never affected until the 
last stage. 



Excito-motor spasms of a tonic 
character in groups or groupings 01 
muscles, with marked loss of cutane- 
ous and muscular sense. 

Reflex movements common. 

Vomiting urgent and uncontrolla- 
ble. 4 



Incoordination of movement with 
cutaneous formication, partial anaes- 
thesia, muscular hyperalgia, but no 
tetanic spasms. 

Reflex movements rare. 

Vomiting not so severe. 



50 DIFFERENTIAL DIAGNOSIS. 

Temperature rarely exceeds ioo°. Temperature often rises to 105 °. 



Purpuric maculae diffuse and gen- 
eral 

Death usually takes place from 
coma. 

Prognosis grave. 

Post mortem appearances reveal the 
membranes over the superior cerebral 
convolutions and posterior columns of 
the cord as the seats of lesion. 



Maculae never seen in the desudate 
form. 

Death usually takes place from 
apncea. 

Prognosis hopeful. 

Post-mortem appearances reveal the 
membranes over the base of the brain 
and anterior column of the cord as 
the prime seat of lesion. 



This distinction has, however, not been wholly accepted by Ameri- 
can authorities. Dr. Da Costa questions the main point of difference 
— the temperature; and Dr. Alfred Stille writes : "The whole medi- 
cal literature does not contain a single case of sporadic idiopathic 
cerebro-spinal meningitis with the characteristic sudden onset of the 
epidemic disease." From that writer's admirable monograph* we 
extract the following exhaustive comparison of meningitis and typhus, 
with which latter it has often been confounded : 



EPIDEMIC MENINGITIS. 
A pandemic disease ; occurs in places 
remote from one another and without 
intercommunication. 

Attacks all classes of society. Is 
never primarily developed by squalor 
and deficient ventilation. 

Is not contagious. 

More males than females attacked. 

More young persons than adults 
attacked. 

Generally occurs in winter. 



TYPHUS. 

Essentially an endemic disease. 
Always due to local causes. Spreads 
by intercommunication only. 

Attacks primarily the poor, filthy 
and crowded alone. 



Contagious in a high degree. 
The two sexes equally affected. 
More adults than young persons. 

Epidemics irrespective of season. 



* Epidemic Meningitis, pp. 107, 117. 



FEVERS. 



51 



MENINGITIS. 
Eruptions are wanting in, at least, 
half the cases ; they occur within the 
first day or two. 

The eruptions are very various, in- 
cluding erythema, roseola, urticaria, 
herpes, etc. Ecchymoses are com- 
mon. 

Headache acute, agonizing, tensive. 



TYPHUS. 

The eruption is rarely absent, and 
appears between the fourth and the 
seventh day. 

The eruption is uniformly roseolous, 
and then petechial. Ecchymoses are 
rare. 



Headache dull and heavy. 



Delirium often absent ; often hys- Rarely absent; usually muttering, 
terical, sometimes vivacious, some- i Rarely begins before the end of the 
times maniacal. Generally begins on first week. 
the first or second day. 

Pulse very often not above the nat- I A slow pulse exceedingly rare ; its 
ural standard; often preternaturally \ rate pretty constantly between 90 
frequent or unfrequent. Is subject and 120 . 
to sudden and great variations. 



The temperature is lower than that 
recorded in any other typhoid or in- 
flammatory disease. It is also very 
fluctuating. 



The temperature is always more or 
less elevated, and it does not fall until 
the close of the disease. The skin is 
hot, burning and pungent to the 
touch. 



The body emits no peculiar smell, i The mouse like odor of typhus is 

. characteristic. 



The tongue is generally moist and ' The tongue is generally dry, hard 
soft ; sordes of the teeth, etc., is rare, j and brown, and the teeth and gums 

fuliginous. 



Vomiting, generally of bilious mat- 
ter, is an almost constant and urgent 
symptom, especially in the first ^tage. 

Pains in the spine and limbs of a 
sharp and lancinating character are 
usual, and evidently neuralgic. 



Vomiting is rare and not urgent. 



Pains are dull, heavy, and appar- 
ently muscular. 



52 



DIFFERENTIAL DIAGNOSIS. 



MENINGITIS. I TYPHUS. 

Tetanic spasms in a very large pro- 1 Tetanic spasms are unknown in 
portion of cases, and within the first typhus. Convulsions sometimes oc- 



two or three days. 

Cutaneous hyperesthesia a promi- 
nent symptom. 

Strabismus common. The eye, if 
injected, has a light red or pinkish 
color. The pupils are often unequal. 



cur, due to pyaemia. 

The sensibility of the skin is gen- 
erally blunted. 

Strabismus rare. The blood in the 
conjunctival vessels has a dark hue; 
the pupils are always equal. 



Duration very indefinite ; but gen- 
erally from four to seven days. 

The blood is often highly fibrinous. 

The lesions, unless in the most rapid 
cases, consist of a fibrinous or puru- 
lent exudation in the meshes of the 
cerebo-spinal pia mater. 

Mortality from 20 to 75 per cent. 



Deafness is often complete and per- J Deafness is hardly ever permanent, 
manent. or attended with signs of disorganiza- 

tion of the ear. 

Duration from twelve to fourteen 
days. 

Blood never fibrinous. 

There are no inflammatory lesions 
whatever. 



Mortality from 8 to 40 per cent. 



ACUTE TUBERCULAR (GRANULAR) MENINGITIS. 
This serious disease is apt to be confounded, especially in the 
adult, with typhoid or typhus fever, the exanthemata and pneumonia. 
The following characteristics of the disease, as given by Drs. Regi- 
nald Southey and Hamilton, will serve to distinguish it: 

1. The prodromal symptoms of this form of meningitis are well 
marked. The history of the case usually records an illness that has 
endured some two or four weeks, but one which has not attracted 
much attention until distracting headache, with some delirium at 
night, has supervened. 

2. Vomiting is generally the first and most important symptom. 
Headache is invariably present. 

3. After two or three days there is a marked rise of temperature, 
say from 101 to 105 , with greatly increased pulse. 



FEVERS. 5 3 

4. The bowels are constipated and not tender to firm pressure. 
Very little nourishment is voluntarily taken. The abdomen becomes* 
retracted, and the aspect of the patient, with half-open eye-lids, or 
some slight paralysis of these, becomes highly diagnostic. 

5. There is no characteristic rash. The so-called tache cerebrate of 
this form of meningitis is not a true eruption, but is produced by 
pressure or contact. When the finger is drawn across the skin it 
leaves a vivid red mark, which has been considered a pathognomonic 
sign of the disease. 

6. The skin is hyperaesthetic, the delirium slight and transitory, 
the temper obstinate and unaccommodating, 

7. There are general muscular pains, followed first by stiffness, and 
then by slight paralysis, as shown in the imperfect co-ordination of 
the muscular movements, in tremblings and in twitchings. The mus- 
cular pain and stiffness are often first complained of in the nape of 
the neck, and then in the muscles of the back. 

8. Slight epileptiform convulsions are observed, followed by paral- 
ysis of motion in the limbs or parts convulsed ; this paralysis being 
most usually of a transitory or temporary kind. Among the paral- 
yses most characteristic are those affecting the optic commissure and 
oculo-motor tracts, causing a slight internal squint, with dilated in- 
active pupil of one eye, with drooping of the same eyelid, and paral- 
ysis of the facial nerve upon one side. The paralysis of the limbs, 
although usually a hemiplegia, is seldom one that invades the body 
upon one side in its entirety. Further, its mode of attack is grad- 
ual ; usually, the arm and leg are affected upon the same side, but 
the facial muscles are not involved. 

YELLOW FEVER. 
The name Yellow Fever is misleading, as the coloration of the skin 
to which it refers is not an invariable nor even a common sign of the 
disease. According to Dr. Greensville Dowell * the skin does not 
turn yellow in more than one case in six, and many die before there 
is the least appearance of yellowness even in the eyes. Of those 

* Yellow Fever and Malarial Diseases. 



54 DIFFERENTIAL DIAGNOSIS. 

who die after the black vomit has set in, not more than one in three 
presents the yellowness. 

The pathognomonic sign of the disease is the black vomit. It is 
brownish black, semi-fluid, with a glistening reflection and acid reac- 
tion, and varies in quantity from a mere stain on a handkerchief to 
many pints in the twenty-four hours. It, however, is not thrown up 
in more than one in three fatal cases. 

The usual course of the disease as witnessed in the southern and 
southwestern states is as follows : 

1. Onset with a chilly feeling along the spine passing intoactual rigor. 

2. Pain in the head, severe in proportion to the malignancy of the 
disease. 

3. Fever slight, tending to perspiration. 

4. Remission after a period varying from twenty-four hours to five 
days. 

5. The secondary fever, commencing usually without a chill ; it 
runs an indefinite course. 

The coloration of the skin begins at the white of the eye, and ex- 
tends over the forehead, chest, abdomen, and extremities. The urine 
is high-colored and stains linen, and in some cases the perspiration 
gives the same yellowish stain. 

The shades which separate the symptoms of one fever from those 
of another, in warm climates, are sometimes of such gentle gradation 
that prima facie they seem to belong to one and the same disease, and 
this more especially refers to the yellow and remittent class of fevers, 
between which so slight is sometimes the distinction, that remittent 
has frequently been considered and classified as true yellow fever; for 
in the prominent symptoms which present in both yellow and remit- 
tent fever a great similarity obtains; both take their origin in paludal 
soils, both in their course offer symptoms of so seemingly similar a 
nature, that the shades which differentiate them are so slight as to fre- 
quently escape the conscientious observer and cause him to fall into 
indefensible interpretations. But this apparent similarity vanishes on 
close and continuous inspection, for then essential and distinctive 
marks are observed, which stamp each with an individuality, and which 
characterize each as a separate disease, distinct in its essence and dif- 



FEVERS. 



55 



fering significantly one from the other. These differences maybe sum- 
marized as follows (J. J. L. Donnet, Da Costa, Dowell, and others) : 



YELLOW FEVER. 

Is essentially of an infectious na- 
ture, and found in cities. 

Chiefly vigorous and young consti- 
tutions fall victims to it. Colored 
population less liable than white. 

Restricted chiefly to the yellow 
fever zone. 

Is of a continued type ; remissions 
not marked. 

Usually attacks at night. 

Severe nausea and vomiting through- 
out. Epigastric tenderness early and 
decided black vomit. Headache oc- 
cipital. 

Hemorrhages from the gums and 
various parts of the body. 

Tongue clean or but slightly 
coated ; pulse variable, becoming 
slow in the last stages. 

Eye highly injected and humid; 
expression often fierce or anxious. 

Pain in the back very severe ; also 
pain in the calves and over the eyes. 



Delirium 
clear. 



rare ; mind generally 



Urine generally albuminous ; sup- 
pression common. 

Muscular prostration slight; con- 
valescence rapid ; no sequelae. 



BILIOUS REMITTENT FEVER. 

Is not of an infectious nature, and 
usually found in the country. 

All ages and constitutions are lia- 
ble, and the weakest most so. Col- 
ored population as liable as white. 

Is to be found in all parts of the 
world where marshy soils prevail. 

Remission observed in the morn 
ing. 

Usually attacks in daytime. 

Nausea and vomiting moderate. 
Epigastric tenderness slight. Head- 
ache frontal 



No hemorrhagic tendency. 



Tongue heavily coated ; pulse va- 
ries little, remaining quick until con- 
valescence sets in. 

Eye and physiognomy not peculiar. 



Rachialgia slight or absent; head- 
ache moderate. 

Delirium frequent ; mind always 
dull. 

Albuminous urine rare ; suppres- 
sion also rare. 

Much muscular prostration; con- 
valescence slow ; sequelae various and 
tedious. 



56 



DIFFERENTIAL DIAGNOSIS. 



YELLOW FEVER. 

Liver affected 

Spleen not affected. 

One attack affords an almost cer- 
tain immunity. 

Mortality very high. 

Peculiar smell often perceptible. 

Never merges into imermittent. 

Treatment unsatisfactory ; quinine 
useless. 



BILLIOUS REMITTENT FEVER. 
Liver not affected. 

Spleen invariably affected. 

One attack seems rather to predis- 
pose to others. 

Mortality slight. 

No peculiar smell observed. 

Often merges into intermittent. 

Quite amenable to treatment ; an- 
tagonistic power of quinine beyond 
question. 



Autopsies show great congestion, i Autopsies show congestion of the 
inflammation, ulceration and soften- , stomach, but rarely inflammation, 
ing of the stomach. Liver enlarged, ' Liver of an olive or bronze hue, 
yellowish in color, its secreting cells not fatty. Spleen enlarged, 
filled with oil globules. Heart often i 
exhibits disintegration of the muscular j 
fibres. 



RELAPSING FEVER. 

Of late years epidemics of this disease have appeared at various 
points in this country. It is eminently contagious in character, and 
a physician should be prepared to recognize it early. The invasion 
is sudden, the fever soon developed and high, the pulse very rapid, 
the skin often jaundiced, and the temperature elevated (io6°-l07°). 
Toward the close of the first week the symptoms rapidly subside, and 
convalescence seems at hand ; but after about another week the 
symptoms all return with as much violence as ever, to again disap- 
pear, as a rule, after four or five days. 

The epidemic prevalence of the disease, its sudden invasion, the 
persistence without remission of the high febrile symptoms, give it a 
peculiar physiognomy. 

The characteristic feature of the disease, asserted by some to be 
truly pathognomonic, is the presence of spirilla in the blood. The fol- 



FEVERS. 57 

lowing method of demonstrating them is that recommended by Dr. 
R. Albrecht, of St. Petersburg:* 

Spread out a drop of blood on a slide, not too thin; let it dry; 
treat it with a drop of acetic acid, and repeat it in a few seconds. By 
this means all the fibrin and blood-corpuscles will be destroyed and 
dissolved, and after careful washing away of the acid with distilled 
water, and final drying, the preparation is ready for use. With a 
little care in washing, which must not be in a stream, the spirilla are 
not lost, especially if the preparation has been dried for six to twelve 
hours before being treated with acetic acid. The glass slide then 
looks quite transparent, and at the place where the drop of blood was 
it looks a little dusty. Under the microscope the nuclei and nucleoli 
of the white blood corpuscles are visible, and between these the 
spirilla lie in great numbers and in the most distinct arrangement 
and position, showing up very beautifully and distinctly. They give 
the impression of being thicker than they generally are, probably 
because they are no longer imbedded in a highly refracting substance 
— plasma. 

Relapsing fever is liable to be mistaken for one of the forms of con- 
tinued fever. Its epidemic prevalence will naturally put the physician 
on his guard. It is, moreover, especially a disease of the lower classes 
who suffer from insufficient food and filthy surroundings. In most 
cases it is associated with jaundice, which is a rare complication in 
typhoid. When the disease rapidly abates, and this cessation is fol- 
lowed by the characteristic relapse, no reasonable doubt as to its 
nature can be entertained. The main distinctions between relapsing 
and typhoid may be thrown into a comparative view as folows : 



RELAPSING FEVER. 

Invasion sudden. 

Bowels generally constipated. 

Liver engorged, skin yellow, ten- 
derness over epigastrium. 



TYPHOID FEVER. 

Invasion gradual. 

Generally diarrhea. 

No yellowness ; tenderness over 
right iliac region. 



St. Petersburg Med. Wochenschrift, June, 1878. 



5 8 



DIFFERENTIAL DIAGNOSIS. 



RELAPSING FEVER. 

Temperature high, io5°-io7°. 

Critical sweats with diminution or 
cessation of the febrile symptoms and 
relapses. 

Spirilla in the blood. 

Splenic enlargement. 

No characteristic eruption. 



TYPHOID FEVER. 

Temperature below 104 . 

These phenomena absent ; symp- 
toms continuous. 



No spirilla. 

Spleen not materially enlarged. 

"Rose spots,'' inflammation of 
Peyer's glands. 



CHAPTER II. 

DISEASES OF THE BLOOD. 

Contents. — The Dyscrasia?. The Arthritic, Dartrous, or Rhenmic 
Dyscrasia. The Scrofulous or Strumous Dyscrasia. The Syphilitic 
Dyscrasia. The Tuberculous Dyscrasia. Rheumatism. Chronic 
Rheumatism. Gout. Rheumatic Arthritis. Pernicious Ancemia 
and Leukemia. 

THE DYSCRASLE. 

As is justly remarked by Professor Theodor Billroth, in his Sur- 
gical Pathology, while it is true that there are some objections to the 
employment of the term dyscrasia?, as committing one to a humoral 
pathology, these are overbalanced by the fact that there are certain 
well-defined, long-recognized, inherited physical peculiarities, which 
render the person possessing them unusually prone to certain dis- 
eases and complications, and which lend a complexion of their own 
to very many affections seemingly remote in form and pathology. 

These constitutional tendencies may as well be known by the term 
Dyscrasia?, as by any other; and those who deny their existence 
altogether, as has become fashionable of late years in some quarters, 
do so in disregard of the nigh unanimous observations of surgeons 
and physicians for centuries. 

The principal dyscrasiae are: I. The artliritic, sometimes called 
dartrous or rheumic, believed to be pathologically akin to gout 
and rheumatism; 2. The strumous, or scrofulous; 3. The syphilitic, 
and 4. The tubercidous or phthisical; the three last mentioned, in the 
opinion of some, being derived from a common ancestral taint. 

(59) 



60 DIFFERENTIAL DIAGNOSIS. 

THE ARTHRITIC, DARTROUS, OR RHEUMIC 
DYSCRASIA. 

The following are the signs as stated by Professor Hardy, of 
Paris : Persons who have this diathesis appear to enjoy good health, 
but their skin is habitually dry, and their perspiration scanty. They 
often experience a lively itching without eruption. The appetite is 
generally well developed, and they are apt to eat a much greater 
quantity of food (especially animal food) than others in analogous 
conditions. Another important peculiarity is the extreme sensibility 
of the skin and the facility with which it is influenced by the lightest 
and most fugitive impressions. Sometimes general excitement, alco- 
holic excess, watching, use of coffee, of certain kinds of food ; some- 
times a local excitement, irritating frictions, or the application of a 
plaster, will give rise to an eruption, often ephemeral, which reveals a 
peculiar predisposition of the economy, and the existence of a latent 
vice which needs but a favorable occasion to manifest itself. 

To this diathesis Hardy ascribes eczema, lichen, psoriasis and pity- 
riasis, among diseases of the skin.* 

Mr. Prescott Hewett adds that when a patient complains of dys- 
pepsia more or less troublesome, frequent deposits of lithates in the 
urine, slight eczematous eruptions on the skin from time to time, 
anomalous wandering pains in various muscles, sharp, deep-seated 
pains in the tongue, continuing for two or three days, and then dis- 
appearing altogether for a while, crackling about the cervical spine 
on slight movements, some, it may be, very slight, knottiness about 
the smaller joints of the fingers — we may be very certain that he has 
the arthritic diathesis. 

Sir James Paget adds to the above : Small nodules in the cartilages 
of the ears {tophi)-, nodular enlargement of the knuckles; thickening 
of the cutis, with subcutaneous bursae over the knuckles, chiefly be- 
tween the first and second phalanges of the fingers; thickening of the 
palmar fascia, adhering to the cutis, and producing contraction of the 
fingers; spontaneous pain in the tendo-Achillis; pain in the heel; 

* Maladies de la Pean, Paris, i860. 



DISEASES OF THE BLOOD. 6 1 

frequent and persistent erections at night not connected with any 
sexual feelings ; " burning soles" and " burning palms ;" sensations 
of hot, tingling and burning patches of the skin of the thighs, with- 
out external appearances of redness or eruption ; patches of " dry ec- 
zema." 

In such patients, an injury may be followed by a well-marked at- 
tack of gout; or the trouble may linger, with pain and occasional 
swelling, and with constantly increasing distrust of surgery and the 
surgeon, till some one suspects the existing taint of the arthritic dia- 
thesia, and acting on the suspicion, addresses his remedies to it, and 
promptly cures the local trouble. 

THE SCROFULOUS OR STRUMOUS DYSCRASIA. 

This form of blood poisoning has been aptly termed by Mr. Jona- 
than Hutchinson, "the basis-diathesis on which both gout and rheu- 
matic arthritis are built, and which to a large extent is indifferent and 
common to both." When a man with such a diathesis becomes 
affected with a renal disease, gout develops itself; otherwise he will 
probably have rheumatism. In many families it is observed that the 
males have gout, the females rheumatism. The explanation is not far 
to seek.* In another lecture Mr. Hutchinson describes gout as 
" chronic rheumatism plus a diatetic derangement." 

Many skin diseases, nervous affections so-called, " cramp colic," 
headaches, sciatica, vertigos, palpitation, and obstinate dyspepsia are 
really latent gout. In such cases there is usually a history of antece- 
dent or hereditary rheumic diathesis, frequent acid eructations, the 
emission of pale, limpid, acid urine, of low specific gravity, and with 
traces of sugar or albumen or both; some varicosity of the veins ; the 
nails are brittle ; and there is slight redness around the eye indicative 
of mild chronic conjunctivitis (Dr. J. Russell Reynolds). 

Sir James Paget defines the principal signs of scrofulous constitu- 
tion to be slowly progressive and long abiding inflammations, pro- 
voked by less causes than would excite inflammation in healthy 
persons, the inflammatory process tending to the production of 

* Medical Times and Gazette, June, 1876. 



62 DIFFERENTIAL DIAGNOSIS. 

"cheesy" matter; permanent incisors, with their borders barred, cre- 
nated, thin and brittle ; the mucous membrane of the lower turbinated 
bone swollen, puffed and congested; a long abiding ozaena in early 
life, with frequent or daily discharge of scabs ; general swelling, with 
glandular enlargement of the whole naso-palatine mucous membrane; 
a granular pharynx, with its lining membrane more or less thickly 
scattered with prominent glands; the perforating ulcer of the nasal 
septum — these are some of the minor signs. Still more positive are 
enlarged and suppurating lymph glands discharging curdy pus, and 
slowly healing with red-banded and barred scars ; pustules by the 
edge of the cornea; frequent impetigo with swollen glands ; periosteal 
swellings of the phalanges ; chronic thickenings of synovial mem- 
branes; obstinate otorrhea. If a patient is found to have or to have 
had any few of these, he may justly be pronounced scrofulous, and 
scrofula may be suspected in any localized morbid process in him. 
Or, if these diseases are known to have occurred singly or together in 
many members of a family, we should look out for scrofula as an 
element of whatever disease may appear in any member of that family. 

Dr. Francis Delafield, of New York city, observes* that practi- 
tioners in this country see comparatively so little of scrofula that it is 
difficult for them to appreciate the prominent place it holds in the 
minds of physicians in European countries. It is a condition which 
is hardly susceptible of a definition, and yet it is not hard to under- 
stand what is meant by the term. 

It means this : When an individual acquires an inflammation of a 
mucous membrane, of the skin, of the joints, of the bones, of the genito- 
urinary apparatus, or of almost any part of the body, such an inflam- 
mation usually runs an acute course and terminates in resolution, or 
in suppuration, or in the formation of organized new tissue. But, if 
the inflammation, instead of doing this, simply reaches a certain point 
and stays there, and then, instead of resolving or suppurating merely, 
goes through a succession of degenerative changes, such an inflam- 
mation is said to be scrofulous. 

The scrofulous inflammations have several well-marked character- 

*N. Y. Medical Record, Vol. x, p. 338. 



DISEASES OF THE BLOOD. 63 

istics. They are very slow in their progress ; they are vtiy rebellious 
to treatment ; they are accompanied by an extensive cellular infiltra- 
tion of the inflamed parts, so that when the degenerative changes 
ensue there is large destruction of tissue. The degeneration which 
occurs in the products of such a scrofulous inflammation is peculiar 
in its nature; it is commonly called cheesy degeneration, and consists 
in the transformation of the products of inflammation into a dry, yel- 
low mass, composed of amorphous granular matter. Examples of 
this form of inflammation will at once suggest themselves. Caries of 
the vertebra, hip-joint disease, white swelling of the knee-joint, scrofu- 
lous orchitis, and enlarged lymphatic glands, are all of frequent occur- 
rence. 

THE SYPHILITIC DYSCRASIA. 

Apart from the special recognition of constitutional syphilis, it is 
of the utmost importance for the physician to be on the alert to rec- 
ognize and meet the syphilitic dyscrasia as it exists, (i) in the infant- 
ile period of life by inheritance, and (2) in advanced years, in the 
condition of latency. 

Mr. Jonathan Hutchinson, F. R. C. S., states that in the infantile 
period we recognize syphilis by the peculiarity of certain single 
symptoms, or else, by the peculiar grouping of several different 
symptoms. 

The rash on the skin is one of the commonest evidences. It is 
usually erythematous or papular, of a peculiar red or coppery tint, 
in abruptly-margined patches. Pustular, vesicular, and bulbous 
rashes and condylomata about the anal orifice are also frequent. 

The snuffles, a peculiar, obstinate coryza, is almost always present. 

Iritis and a tendency to deep-seated inflammations of the eye are 
often met with. 

At or about the age of one year, if the child survives, these symp- 
toms usually all disappear, and the disease enters upon its stage of 
latency. 

To detect its presence in the system at this period, we must first 
look to the evidences of past disease. 

A sunken bridge of nose, caused by the long continued swelling 



64 DIFFERENTIAL DIAGNOSIS. 

of the nasal mucous membrane when the bones were soft ; a skin 
marked by little pits and linear scars, especially near the angles of 
the mouth ; the relics of an ulcerating eruption in early life ; a protu- 
berant forehead consequent upon infantile arachnitis ; clouds in the 
cornea from past iritis — are all signs pointing to the constitutional 
taint. 

The teeth furnish valuable aid. The upper central incisors are nar- 
row and short, and notched in the centre in a half-moon shape, a shal- 
low furrow running from this notch to the gum ; the canines are nar- 
row, rounded and peg-like; there are usually interspaces between the 
teeth. This may be considered an almost absolute sign of the taint. 

The general growth is not often retarded, but the complexion is an 
important indication. It is exceedingly rare to meet a florid, good 
complexion in a young adult who is the subject of this taint. It is 
almost always pale. 

Such persons, seemingly in full youth and vigor, generally have 
little spontaneous physical energy ; they do not seek athletic exercise 
nor the trials of strength ; and are languid in motion. 

Other signs which may be mentioned are : a patch upon the cho- 
roid, an optic irregular neuritis ; a faint interstitial keratitis ; an un- 
equal thickening of the vocal cords, with cicatrices of old ulcera- 
tion ; and last, but not least — and especially where syphilis is asso- 
ciated in a gouty habit of body — psoriasis upon the sides of the 
tongue, as well as an indurated irregular thickening of the lower 
bowel. 

THE TUBERCULAR DYSCRASIA. 

In, many instances tubercular disease is brought about by the stru- 
mous dyscrasia, and is by many identified with it. The physical 
characteristics of scrofulous subjects belong also to the majority of 
consumptives in a greater or less degree. Others are pre-disposed to 
the disease, through defective oxygenation caused by unfavorable 
form of the thoracic walls. But the researches on this subject are 
still incomplete, and it is well to bear in mind the words of Dr. A. T. 
H. Waters : 

"There is no temperament which does not furnish victims to con- 



DISEASES OF THE BLOOD. 65 

sumption ; nor can we say that there is any conformation of the 
body which is characteristic of the phthisical. I have seen men and 
women with the best developed frames and the most ample chests 
attacked with phthisis. You must not, therefore, be misled by the 
existence of these conditions, by the appearance of robustness in 
your patients, into imagining that they cannot possibly become the 
subjects of this disease." 

RHEUMATISM. 

Ordinarily an attack of acute rheumatism is recognized without 
difficulty by the pains in the joints, their swelling and tenderness, the 
shifting character of the disorder from joint to joint, and the absence 
of the symptoms of disturbance of the brain and stomach so common 
in continued fevers, as well as of the intermissions or remissions of 
periodic fevers. 

Nevertheless it is true, as remarked by Dr. S. O. Habershon,* that 
whilst there are many characteristics of true rheumatic disease, few 
maladies are more easily mistaken, and there is no sign which is 
uniformly present. Pain is, perhaps, the most constant indication, 
with stiffness of one or other joint; but rheumatic pericarditis may, 
and often does exist, without any pain whatever. The same may be 
said in reference to febrile symptoms, to increase of temperature, 
and to changes in the urine ; none of these signs is pathognomonic. 
Many maladies are designated rheumatic which have no connection 
with that disease. 

1. Diseases of the spine are often said to commence with an attack 
of rheumatism ; but it will generally be found that the pain in the 
course of the nerves or in the fibrous tissues arises from direct impli- 
cation of the nerves or their centres. 

2. The same remark applies to pain produced by the pressure of 
cancerous, aneurismal, or other tumors. Thus cancerous disease of 
the lumbar glands is often mistaken for lumbago; so also the pain 
from aneurismal disease of the thoracic and abdominal aorta, when no 
pulsating tumor can be detected, is referred to rheumatism. 

* Half- Yearly Compendium of Medical Science. III. 

5 



66 DIFFERENTIAL DIAGNOSIS. 

3. During the course of renal disease, abnormal irritation arises 
not only in the serous membranes, producing pericarditis, pleurisy, 
peritonitis, etc., but a similar change happens with the synovial mem- 
branes, and a form of disease is induced which simulates rheuma- 
tism. 

4. In chronic poisoning by lead, vague pains in the fascia, as well 
as in the joints, have been designated " saturnine arthralgia." 

5. Periosteal disease is occasionally a source of fallacy in the diag- 
nosis of rheumatism. 

6. Shingles or herpes zoster may be found in the course both of the 
cerebral and spinal nerves ; and the severe pain which precedes the 
eruption of the vesicles, and which also follows their disappearance, 
closely simulates local rheumatism. 

7. A more important disease, and one which is attended with fatal 
issue, is pycemia. It closely resembles rheumatism; for, with rigor 
and febrile symptoms, there is fixed pain and swelling in the joints — 
first one, then another, being affected, though without subsidence of 
those parts first attacked. But whilst there may be some similarity 
in the symptoms, the prognosis is widely different. The one is gen- 
erally a curable disease ; the other, a fatal one. 

8. Acute synovitis closely resembles rheumatism, having pain and 
heat in the joint with distension. But as a rule it affects only one 
joint; it is never subject to metastasis; and there is little or no effu- 
sion into the surrounding tissue. The accumulation of fluid in the 
joint is greater, but the constitutional symptoms are less prominent. 

9. Milk leg occurs after fevers, or, in woman, after confinement. 
The limb swells throughout, becoming white, firm, hot and shining, 
and pits but little on pressure. The history of the case and appear- 
ance of the limb are usually sufficient to form the diagnosis. 

CHRONIC RHEUMATISM. 

The most common form of chronic rheumatism is that which 
affects the muscles, and it is frequently by no means easy to distin- 
guish the pains due to the rheumatic diathesis from those of a 
wholly diverse etiology. 



DISEASES OF THE BLOOD. 67 

The principal distinctions are 

1. From neuralgia. Neuralgic pains are usually confined to the 
distribution of one nerve ; they are not increased by motion or pres- 
sure; they are not attended with diffused soreness ; and they are var- 
iable in intensity, and are not attended with acid secretion. 

2. From the pains of organic lesions. These are usually so clearly 
localized as to point to their origin. Nevertheless the pain in the 
right shoulder, symptomatic of hepatic disease, and especially of an 
abscess approaching the serous surface of the liver* and the sympa- 
thetic pain down the left arm in some cases of heart disease, are 
often carelessly looked over, and their significance unheeded, by 
classing them as rheumatic. Intercostal rheumatism has included 
pleurisy, pleurodynia, broken ribs, herpes, neuralgia, the peculiar 
pain, generally of the left side, found in women, and connected with 
menorrhagia and leucorrhoea; the pain on either side, which is inti- 
mately connected with debility and anaemia; and again is confounded 
with that condition of pain and soreness of the muscles developed by 
overwork, and attended with both muscular and cutaneous hyperes- 
thesia, designated by Inman "myalgia." 

3. From the osteocopic pains of syphilis. The history of the case 
throws some light ; but as this often cannot be had, it should be re- 
membered that syphilitic periostitis evinces a decided partiality for 
the periosteum and shafts of the long bones, and is very generally 
accompanied by nodes, especially in the anterior surface of the tibia, 
which are almost pathognomonic. There is often, too, a more 
marked cachexia than is found along with non-specific rheumatism. 
The clavicle, humerus, and forearms, are frequent locations of this 
form of rheumatism. As well as its favorite seats and accompanying 
nodes, there are evidences of skin and throat -affections, a mutilated 
iris, etc., which will assist in forming a correct diagnosis. Further- 
more, the ready response to a specific treatment aids in distinguishing 
syphilitic pains. 

4. From progressive locomotor ataxy. Ataxic patients often bitterly 
complain of supposed rheumatic pains. These pains, in locomotor 
ataxy, come on in severe pangs — "stabbing, boring, shooting like 
lightning, flitting from one place to another in a very erratic manner, 



6S DIFFERENTIAL DIAGNOSIS. 

and recurring paroxysms lasting from a few minutes to many hours." 
Their suddenness is their especial characteristic, and should always 
put the medical observer on his guard to look out for the other indi- 
cations, as loss of tactile sensibility, etc. These pains may be accom- 
panied by a feeling of coldness, thus closely simulating some forms of 
rheumatism. The importance of them lies in the prognosis, as the 
pains of locomotor ataxy are not to be relieved by art. 

5. The pains of chronic renal disease often closely simulate lumbago , 
or muscular rheumatism of the loins. No absolute distinction can be 
positively drawn except from examination of the urine; but in some 
forms of renal disease albumen is often absent for long periods to- 
gether. The urine varies greatly, however, in quantity, and when 
great in quantity is usually of low specific gravity, and contains granu- 
lar casts, which, however, are often few in number and not easily 
found. An absolute diagnosis is, however, not always attainable. 
We are then thrown back upon the rational symptoms, and the dis- 
tinguishing characteristics may be found to run somewhat in the 
following directions : Rheumatism is associated with the fibro-serous 
texture; in lithiasis the poison has more affinity for the true serous 
surfaces, and is often the cause of pleurisy and peritonitis. Lithiasis 
more affects the muscles, and rheumatism rather the large joints. 
Diarrhoea, vomiting, and other affections of the mucous membranes, 
as bronchitis, accompany lithiasis ; and in these it differs from rheu- 
matism. Lithiasis is accompanied by headache, especially of the ver- 
tex (persistent and recurring vertical headache is almost pathogno- 
monic of lithiasis), or the pain may be frontal. (Fothergill.) 

A typical effect of the acid diathesis of chronic rheumatism is the 
Rheumatic markings of the teeth, to which attention has been directed 
by Dr. L. G. Noel.* 

These markings seldom appear until after middle life is past. They 
are most frequent upon the crowns of the teeth, though they are 
sometimes seen upon their buccal and labial surfaces. It is that con- 
dition of the teeth, treated of in dental works as " spontaneous abra- 
sion." 

* Nashville yournal of Medicine and Surgery, Feb., 1 875. 



DISEASES OF THE BLOOD. 



6 9 



The abrasion often begins as decay in the fissures on the grinding 
surface of the molars and bicuspids, but instead of following the tubuli, 
and dipping deep into the interior of the teeth, these become closed 
by a calcareous deposit, as fast as laid open, and the decay spreads 
out into a wide saucer-shape. This cupping out of the teeth is not, 
however, confined to the molars and bicuspids, but commencing upon 
the cusps of the canines, and cutting edges of the incisors, as mere 
mechanical abrasion, asperities disappear, the teeth become square 
and polished on end, and presently the surfaces begin to assume a 
concave, instead of their original convex, appearance. This cupping 
out may go on until the pulp is so nearly reached as to become irri- 
tated, to the point of inflammation and death ; but usually its irritation 
is only sufficient to cause a deposition of secondary dentine on the 
interior of its chamber, a part of its substance forming a matrix in 
which lime-salts are deposited. 

GOUT. 
The signs of gout have already been in part referred to (page 59). 
It is not nearly so frequent in the United States as in England, and is 
apt therefore to be mistaken for rheumatism, which it closely resem- 
bles. The following table of differences will facilitate the diagnosis : 



GOUT. 

Generally a hereditary history. 

Occurs usually in males, beyond 
middle age. 

Attacks generally periodic, and last 
about a week. 

The small joints chiefly affected, 
especially that of the great toe, or 
lower extremity. 

Much local pain, redness, oedema, 
and enlargement of veins. 



RHEUMATISM. 

Rarely hereditary. 

Occurs oftener in females, and be- 
fore middle age. 

Attacks dependent on exposure, 
and last several weeks. 

The large joints are those generally 
attacked. 



All these symptoms less marked. 



70 DIFFERENTIAL DIAGNOSIS. 



GOUT. 
Kidneys generally affected ■ little 
fever ; no sweating ; heart not im- 
plicated. 

Chalk stones in the joints. 

Uric acid always present in the 
blood in large excess (Garrod). 



RHEUMATISM. 
Kidneys not involved • fever often 
high ; sweating profuse ; heart often 
implicated. 

Chalk stones never present. 

Uric acid never found in excess. 



Dr. Garrod says that the presence of uric acid in the blood can 
readily be demonstrated by taking a fluidrachm of the serum from 
a blister, adding to it six minims of acetic acid, and placing a thread 
in the mixture. The uric acid, if present, will be deposited in fine 
crystals along the thread. 

RHEUMATIC ARTHRITIS (RHEUMATIC GOUT, ARTH- 
RITIS RHEUMATICA DEFORMANS). 

This is by no means an infrequent disease in this country, and is a 
very serious one. It is now acknowledged by the best authorities to 
be a distinct malady, different in origin, history and treatment from 
both rheumatism and gout. It is common in women and young per-' 
sons, and is not produced by alcoholic or other excesses. It impli- 
cates joints of all size, and in all the extremities. They become 
permanently affected, stiffened and enlarged, but no deposits of urate 
of soda are found in them. The disease frequently shows itself with- 
out fever; the joints swell by serous effusions into the capsules, and 
along with this the ends of the bones enlarge. The integument is 
not inflamed or but moderately so, and the muscles do not appear to 
suffer. The result on the joint may be subluxation, relaxation, or 
anchylosis. The concretions attendant on the disease prove on anal- 
ysis to be of the same composition as bone, with a slight preponder- 
ance of lime (Drachmann). Phosphoric acid is diminished in the 
urine and increased in the blood (Bocher). 

Neither the treatment of gout nor that for acute rheumatism yields 
its usual results in this disease. 



DISEASES OF THE BLOOD. 7 1 

PERNICIOUS ANEMIA AND LEUKEMIA. 

The positive diagnosis of these conditions can only be secured by 
a microscopic examination of the blood. 

In pernicious anaemia, according to Dr. Eichhorst, the character- 
istic appearances are : A portion of the red corpuscles are seen to re- 
tain their normal size, but are marked by an extreme paleness, with 
a tendency to crenation and the formation of rouleaux, while others 
among them attract attention by their small size, which is reduced 
often to one-fourth the diameter of the well formed corpuscles. 
These small ones are more deeply colored, and if allowed to roll over 
under the thin cover-glass, their appearance in profile shows them to 
to have lost to a greater or less extent their tri-concave outline. 

For the examination of the blood in such investigations, Dr. 
Gowers, of London, recommends the use of the hcBmacytometer, by 
which he measures for the purpose of ascertaining the number of red 
and white cells in a given volume of blood. The essential part of 
the apparatus consists of a glass slip, on which is a cell one-fifth of a 
millimetre (.0008 inch) deep. The bottom of this cell is divided into 
one-tenth millimetre squares. Upon the top of the cell rests the glass 
cover, which is kept in its place by the pressure of two springs. In 
estimating the number of corpuscles, the patient's finger is pricked ; 
then by means of a capillary pipette, five cubic millimetres of blood 
are taken up and well mixed up with 995 cubic millimetres of saline 
solution; a drop of the dilution is then placed in the glass cell, the 
cover is adjusted, and the slide is placed in the field of a microscope. 
In a few minutes, all the corpuscles have sunk to the bottom of the 
cell, and are seen lying on the squares ; the number of corpuscles in 
ten squares is then counted, and this, multiplied by 10,000, gives the 
number in a cubic millimetre of blood. The degree of dilution and 
size of the squares are so proportioned that, with normal blood, two 
squares contain about 100 corpuscles, and the number in two squares 
thus expresses the percentage proportion of corpuscles to that of 
health. The proportion of white corpuscles to red or their absolute 
number, may be easily determined during the same observation. 

A simpler method is used by Dr. J. G. Richardson, of Philadel- 



J2 DIFFERENTIAL DIAGNOSIS. 

phia. He spreads a drop of fresh blood thinly on a glass slide, let- 
ting it dry, and then counting the number of white corpuscles. The 
specimens when thus prepared can be kept dry for any length of 
time, if preserved from dust and moisture, and by comparing speci- 
mens of different persons' blood, prepared similarly, the variations in 
the number of white corpuscles can be readily observed. By this 
means he claims to detect leukemia in its early stages. 

Profound anaemia is met with in the following conditions: (i) 
After great loss of blood or exhausting discharges ; (2) where there 
is insufficient nourishment ; (3) in chlorosis ; (4) in cases of malig- 
nant disease; (5) in Bright's and Addison's disease, leucceythemia, 
and chronic poisoning. 

The symptoms of the idiopathic or " progressive pernicious" form 
of anaemia is described by Dr. Byron Bramwell as follows: — A 
profound anaemia, which is associated with marked changes in the 
microscopical characters of the blood, and (in most cases) with the 
presence of retinal hemorrhages. The patient is generally well cov- 
ered with fat, the skin is smooth and soft, the face looks slightly 
swollen, and is of a pale yellow or yellowish-green color. All the 
symptoms of profound anaemia are present, viz., extreme pallor of 
the mucous membrane, great debility, tendency to fainting, dyspnoea 
and palpitation on exertion, buzzing in the ears, headache, subcuta- 
neous oedema, etc.; loud blowing murmurs are heard over the heart 
and great vessels; there is a venous hum in the neck; the pulse is 
very soft and compressible. Attacks of vomiting and diarrhoea are 
frequent; irregular elevations in temperature, transient paralyses, 
haemorrhages from the , mucous membranes occasionally occur. 
The causes of the disease are at present unknown. The disease is 
said to occur more frequently in women than in men. In the ma- 
jority of cases the termination is in death, the end being ushered 
in by profuse diarrhoea, coma, or delirium. 



PART II. 

LOCAL DISEASES. 



CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM. 

Contents. — Cerebral Diseases — Cerebral Congestion and Cerebral 
Hyperemia. Cerebral Hemorrhage, Cerebral Thrombosis and Cere- 
bral Embolism compared. 

Diseases of the Cord — Cerebrospinal Diseases. Comparative 
Table of Locomotor Ataxia, Midtilociilar Sclerosis, Disseminated 
Syphilosis and General Paralysis. The Location of Cerebrospinal 
Lesions. The Forms of Paralysis ; Organic, Functional, Hysterical ; 
with and without tremors; Sclerosis of the Cord; Antero-lateral 
and Posterior Sclerosis. Paralysis Agitans. Reflex Paraplegia and 
Paraplegia from Myelitis. General Paralysis of the Insane. 
Syphilitic General Paralysis. Pseudo-hypertrophic Paralysis. 
Paralysis from Lead Poisoning. 

Neuralgia — Comparison with Myalgia ; with Spinal Irritation ; with 
Cerebal Abscess. Spinal Irritation. Hysteria. Epilepsy. Hyster- 
ical Paralysis. Insanity ; Mania and Melancholia compared. 

CEREBRAL CONGESTION AND CEREBRAL ANEMIA. 
These two conditions are in their early and minor stages exceed- 
ingly similar in symptoms. The following table, prepared by Ham- 
ilton,* will furnish sufficient limits to distinguish most cases : 

* Nervous Diseases, p. 79. 

(73) 



74 DIFFERENTIAL DIAGNOSIS. 

CEREBRAL ANEMIA. 
Headache (chiefly vertical). 



CEREBRAL CONGESTION. 

Headache (generally diffused). 



Noises in the ears (generally 
" rumbling" or singing). 

Mental disturbance — loss of mem- 
ory, hallucinations. 

Pupils contracted. 



Noises in the ears (generally short 
or sharp). 

Mental disturbance — incapacity for 
mental work. 

Pupils dilated. 



•No heart sounds, except perhaps j Pulse irritable. Aortic murmurs, 
those of insufficiency. Pulse full. sphygmographic tracing almost 

straight. 

Urine not increased, generally con- : Urine passed in large quantities; is 
tains urates and phosphates. I clear and limpid. 

APOPLEXY. 

Apoplexy is to be distinguished from drunkenness, narcotic poison- 
ing, ursemic poisoning, epilepsy, concussion of the brain, cerebral 
thrombosis and embolism. 

Drunkenness. The odor of liquor may excite suspicion. If the 
patient vomits, the ejecta may be tested for alcohol. Or the urine 
may be tested by Anstie's test, as follows : 

I£. Bichromate of potash, i part 

Strong sulphuric acid, 300 parts. Mix. 

To fifteen minims of this, add a few drops of the urine, and if the 
patient has taken a toxic dose of alcohol, the mixture will turn an 
emerald green. In drunkenness the pulse is generally rapid, the pupils 
dilated, the eye injected. The patient can be roused and hiccoughs. 

Narcotic poisoning. In this condition the outset is gradual, there are 
often convulsions and the patient may be roused. In opium poison- 
ing the pupil is contracted ; but it is also so in hemorrhage in the 
frons. The vomiting, the acrid odor of opium and the gradual in- 
tensification of the coma are diagnostic. 

Urcemic poisoning. Here the coma nearly always comes on gradually 
and is preceded by convulsions. It is not deep and the patient may 
be aroused. The stertor of the breathing is more superficial. 



DISEASES OF THE NERVOUS SYSTEM. 



75 



Mr. W. Whittle remarks that in such cases great assistance will 
be had from careful examination of the condition of the heart, as 
nearly always distinctive modifications of the heart sounds will be 
heard, as reduplication of one or both, intensity of second sound, etc.; 
differences also in the arterial tension and cardiac impulse. Of these 
none seem so constant or remarkable as muffling of the first sound. 

There are, moreover, marked prodromata. The skin is waxy and 
aedematous, the eyelids are puffed and the legs and feet swollen. The 
urine is albuminous (but this may also be present in apoplexy). 

Epileptic coma presents a history of convulsions; lasts but for an hour 
or two; there is frothing at the mouth ; and the temperature is elevated. 

In concussion or compression from injuries to the head the skin is 
pale, the pupil dilated, and vomiting occurs. The symptoms are 
usually of short duration and there is a history of injury. 

Syncope is readily distinguished by the feeble pulse, the pale face, 
the quiet respiration and the brief duration of the unconsciousness: 
while in asphyxia the livid face, distressed breathing and blue lip 
which precede the coma indicate its distinction. 

In regard to thrombosis and embolism of the larger cerebral vessels 
the diagnosis is often extremely difficult. The following table of the 
comparative symptoms is drawn up from the works of Bauduy, 
Gelpke, Flint and Hamilton. 



CEREBRAL HEMOR- 
RHAGE. 

Occurs in advanced age, 
with antheromatous arteries. 

Onset generally sudden. 



Hypertrophy of left ven- 
tricle. Alcoholism or other 
debilitating habits. 



Hemiplegia indifferently 
on either side. 

Aphasia ataxic, secondary 
to a loss of consciousness. 
Intelligence much involved. 



CEREBRAL THROM- 
BOSIS. 
In advanced age. 



Development of symptoms 
gradual. 

No rheumatic history. 
Endo-arteritis deformans of 
peripheral arteries some- 
times present. 



Aphasia incomplete and 
primary occasionally absent. 
Intelligence less involved. 
Rarely loss of consciousness. 



CEREBRAL EMBOL- 
ISM. 
Almost always in early or 
middle life. (Flint.) 

Prodromata absent. 



Previous articular rheuma 
tism or other disease lead 
ing to formation of clots 
Cardiac valvular insuffi 
ciency. Coincident embol 
isms are sometimes present 

Hemplegia generally on 
the right side. 

Aphasia amnesic. Reten- 
tion of early mental power. 



DIFFERENTIAL DIAGNOSIS. 



CEREBRAL HEMOR- 
RHAGE. 

Paralysis very marked; 
occurs on either side. 



CEREBRAL THROM- 
BOSIS. 
Paralysis less marked. 



CEREBRAL EMBOL- 
ISM. 
Muscular paralysis exten- 
sive ; nearly always on the 
right side (Flint). 



Apoplectic phenomena 
from the outset. Symptoms 
of cerebral pressure. 



Apoplectic phenomena 
during the last stage. 



Early apoplectic pheno- 
mena. 



Disappearance of the res- 
idual disorder after a mod- 
erate time. 



Recovery slow; lasting Very rapid, or else quite 

hemiplegia may remain. imperceptible disappearance 

of the residual disorder. 



After a few days pain in 
the head and increased tem- 
perature of the body on the 
unaffected side (Flint). 



Not marked. 



Not marked. 



DISEASES OF THE CORD. 

In distinguishing the various forms of disseminated or midtilocular 
cerebro-spinal affections, the following table ^given by Professor 
Charcot will render valuable assistance. The symptoms of great- 
est importance are set up in italics. 

CEREBRO-SPINAL AFFECTIONS. 



Locomotor Ataxia. 



r Epileptiform Apoplectic 
Attacks 



Vertigo 

Diplopia, Strabismus. 



Amaurosis. 



Inequality of Pupils 

Facial Anaesthesia 

Deafness 

Meniere' s Vertigo. 

Laryngismus , 

Embarrassm't of Speech. 



MuLTILOCULAR 

Sclerosis. 



Epileptifor77i Apoplectic 
Attacks 



Disseminated 
Syphilosis. 



Vertigo 

Diplopia... 
Nystagmus 



Amblyopia, White Atro- 

phy 



Epileptiform Attacks. 

Par.H'mipl'gicEpil'y 
Vertigo 



Amblyopia, Optic 

Neuritis. 



Diplopia , 



Headache, Fixed 
Pain 



Embarrassm' 1 tof Speech 

Difficult Deg lutition 

Pneumogastric Palsy Total Facial Palsy.... 



General Paralysis. 



Epileptiform Apoplectic 
Attacks. 



Vertigo. 
Diplopia. 
Amblyopia. 
Inequality of Pupils. 

Headache. 



Emba rrassm't of Speech . 



DISEASES OF THE NERVOUS SYSTEM. 



Locomotor Ataxia. 



MULTILOCULAR DISSEMINATED 



f Gastric Crises. 



Nephritic Crises. 



Wc" 1 < Vesical Crises. 

E2^ 



Paresis of Bladder 
[ Cystitis 



Sclerosis. 



Syphilosis. 



Gastric Crises. 



Non-nervous Crises. 



General Paralysis. 



Paresis of Bladder. 






Girdlepain 

Hyperaesthesia,Ansesthe- 
sis 



Inco-ordinated Movent' t. 

Contractures and Trepi- 
dations 



Lightning Pains. 
Plaques 



Incoordination 

Special Trembling. 



Psedoneural Pains... Lightning Pains : 
Spin' I Hemianoesth" s. i Tingling. 



I Inco-ordination. 



Spasmodic Paraplegia 



Spasmodic Paraple-\ Paresis. Trepidation. 
J gia under form of\ 
Hem ipa rap legia . 



Special Trembling of 
Hand. 



{J 'Si 



( Eschars 

I Arthropathies 

I Fractures 

[_ Muscular Atrophy. 



Eschars 

Arthropathies. 



Muscular Atrophy. 



Eschars. 



Muscular Atrophy. 



In applying these symptoms in practice, we should, of course, give 
first attention to 'those which are most characteristic. Thus, if we 
observe, in a patient, ataxy with nystagmus, we must think of multi- 
locular sclerosis and not of locomotor ataxy (tabetic series), because 
nystagmus is a valuable symptom of multilocular sclerosis. In 
the same way spasmodic paraplegia (recognized by the continual 
trembling movements which are produced when a single blow is 
struck upon the soles of the feet) is much more characteristic of 
syphilosis than of multilocular sclerosis, especially if accompanied 
hy fixed pain, which always indicates a phenomenon of compression. 
Ex.: paraplegia consecutive to Pott's disease. 

In regard to the symptoms of syphilitic nerve disease, Dr. Buzzard, 
of London, points out in a recent monograph that though there may 
be no pathognomonic symptom of the specific origin of a nerve dis- 
order, yet the peculiar grouping of the symptoms " may lead of itself 
to a probability but little short of certainty." 



7» 



DIFFERENTIAL DIAGNOSIS. 



The following three points are especially noteworthy : 

1. The age of the patient. In young adults, free from heart disease 
and disease of the kidneys, syphilis should be suspected as the cause 
of nerve disorder much sooner than in patients of older age, 
whether older in years or only old in constitution. In connection 
with this point, Dr. Buzzard says : " I have little hesitation in stating 
my conviction that, putting aside cases of injury, hemiplegia or para- 
plegia occurring in a person between twenty and forty-five years of 
age, which is not associated with Bright's disease, nor due to embol- 
ism (from disease of the cardiac valves), is, in at least nineteen cases 
out of twenty, the result of syphilis." 

2. "The existence simultaneously of two or more grave lesions c-f 
the nervous system, not necessarily connected," is a condition of great 
significance; "it is exceedingly uncommon except as a result of 
syphilis, and very common in the disorders of the nervous system 
which are consequent on that disease." 

3. " The existence of marked cachexia unexplained by evident dis- 
ease of any of the viscera.". These are sign-posts specially pointing 
to the existence of syphilitic infection. 

THE LOCATION OF CEREBRO-SPINAL LESIONS. 
Much attention has been devoted by neurologists to locate the 
lesions which correspond to the symptoms of the various cerebro- 
spinal diseases. From the studies of Brown-Sequard, Broca, 
Charcot, Gubler, Seguin and others, we may lay down the follow- 
ing general schemes : 

THE BRAIN. 



Lesions of the Right Hemisphere. 
Anaesthesia more complete. 

Paralysis more complete. 

Paralysis of sphincters. 

Alterations of nutrition (edema, es- 
chars, fevers, pulmonary congestion j. 

Disorders of special senses. 

Hysterical symptoms. 



Lesions of the Left He7nisphere. 
Loss of speech (aphasia). 

Paralysis of muscles of articulation. 

Hysteria seldom. 



DISEASES OF THE NERVOUS SYSTEM. 



79 



THE SPINAL CORD. 

Transverse diffused myelitis (acute and chronic) { <*3g^J& t £$Sg, 

(Pat 
Disseminated sclerosis (sclerose en plaques). 



limited portion of the 



Patches of disease situated primarily in the connective 
tissue, and scattered without regard to the "systematic" 
grouping of the nervous elements. 

f Its distribution is " syste- 



"Systematic" myelitis, 
mainly affecting the 
white columns. 



Sclerosis of the posterior columns (locomotor ataxy) 



Symmetrical lateral sclerosis. 



f Poliomyelitis anterior. 



Myelitis of the gray 
matter of the anter- 
ior cornua. 



Acute. 



matic," and, probably^ 

it is primarilya primary 

| disease of the nerve ele- 

| ments rather than of the 

[ connective tissue. 

Ditto, though its pathology is as yet almost 

purely a matter of inference. Its characteristic 

symptom is muscular rigidity. 

' Infantile paralysis. Acute spinal paraly- 
sis of the adult. 



Subacute. 
Chronic. 



Progressive muscular atrophy and pro- 
gressive bulbar paralysis ("labio-- 
glosso-pharyngeal paralysis"). 



Amyotrophic lateral sclerosis 



rNot 

is.K on 

(_ tO! 



Often classified as a special form of po- 
liomyelitis chronica, but characterized 
by the absence of paralysis, except 
such as is directly due to the muscular 
atrophy. 
Ci 



Not yet thoroughly studied, but believed by Charcot and others to involve at 
ce the lateral columns and the anterior cornua ; the characteristic symp- 
ms being atrophy with contracture, beginning in the upper extremities. 



THE FORMS OF PARALYSIS. 

A leading symptom of many diseases of the spinal cord, whether 
functional or organic, is paraplegia. It is very rarely of cerebral ori- 
gin, and may then be distinguished by the co-existence of distinct evi- 
dences of brain disease, as headache, impaired cerebration, and paraly- 
sis of parts supplied by nerves arising above the spinal cord. 

The following classification of diseases giving rise to paraplegia, 
with their characters, has -been proposed by Dr. H. C. Wood, Jr.:* 



ORGANIC. 



Disease of the cord. 



FUNCTIONAL. 
Anaemic. 

Reflex (from peripheral 
irritation, renal, praeputial, 

etc.) 



HYSTERICAL. 
Hysteria. 



Dyscrasic (diphtheritic, 



etc. 



The last mentioned, hysterical, is also functional, but simulates the 
organic more closely than does the second group. (For Hysterical 
Paralysis, see under Hysteria.) 

*On the Diagnosis of Diseases accompanied "by Paraplegia. 1875. 



8o 



DIFFERENTIAL DIAGNOSIS. 



The general distinctions between the organic and functional para- 
plegias may be presented as follows : 



Organic. 
Onset may be almost instantaneous 
or very rapid, though often also grad- 
ual. 

Usually at some period spasm or 
pain in the affected limbs. 

Often a sensation of a band or 
stricture around the waist, girdlepain 
pathognomonic). 

Anaesthesia frequent and often 
complete. 

Retardation of sensation (a per- 
ceptible time elapses between the pa- 
tient's seeing his feet touched and 
feeling that they are), (pathogno- 
monicj. 

Symptoms of paralysis of the No symptoms whatever of vesical 
bladder. I paralysis, except in the hysterical 

■' form. 



Functional. 
The onset always more or less grad- 
ual, except the hysterical form, where 
the paralysis is generally abrupt. 

Spasms or pain rarely or never 
present. 

Not found. 



Anaesthesia absent or but partial. 



Sensation, if felt a tall, is not re- 
tarded. 



Where the bony canal is involved and caries is present, this con- 
dition may generally be discovered by Rosenthal's test. This con- 
sists in passing down the back a pair of electrodes attached to a 
faradaic battery of some power, one pole being placed upon each side 
of the spine. Under these circumstances if there be any caries or 
inflammation of the vertebrae, the moment its locality is reached the 
patient starts or screams from the burning sticking pain caused by 
the passage of the galvanic current through the inflamed tissue. 
Dr. Wood states he has not found this test as trustworthy as its 
originator claimed it to be, and as, apparently, it ought to be. In 
cases simulating caries, however, the pain is probably not so severe 
as where the vertebrae are really affected. Moreover, absence of the 
pain in any case seems to be conclusive evidence of the non-existence 
of bone-disease. 



DISEASES OF THE NERVOUS SYSTEM. 51 

The diseases of the spinal marrow are classified by Dr. Wood 
according to the rapidity of their onset, as follows, the attack being 
considered rapid when decided paralysis has developed within forty- 
eight hours: 

Rapid onset. Slow onset. 



Congestion. 
Meningeal apoplexy. 
Spinal apoplexy. 
Acute myelitis. 



Sexual exhaustion. 
White softening. 
Chronic myelitis. 
Tumors. 



In congestion of the cord the diagnosis rests upon: Suddenness of 
onset; uniform, bilateral loss of voluntary motion, reflex activity and 
sensation; absence of all symptoms of irritation, such as spasms or 
violent pains ; absence of constitutional disturbance. It must also be 
remembered, that the palsy affects first and most severely the lower 
limbs, but may rise to the arms, and, finally, to the muscles of respir- 
ation, and thus prove fatal ; that so far as the paralysis extends, all the 
muscles are involved ; that motion is affected more than sensation; 
and that very rarely, if ever, does ulceration or other indications of 
trophic changes occur. 

In meningeal apoplexy the symptoms are also due to pressure, but 
the effused blood not only disturbs the cord by pressing upon it, but 
also irritates the membranes and the nerve-roots, especially when first 
thrown out. Consequently, in the first few hours or days of a menin- 
geal hemorrhage, there are violent spasms and pains, due either to an 
incipient meningitis, or more probably to a direct irritation of the 
nerve-roots. The extent and amount of the symptoms vary, of 
course, with the position and amount of the hemorrhage. Later there 
are symptoms of pressure varying in intensity with the amount of 
the effusion ; and absence of febrile symptoms, unless decided menin- 
gitis be produced by the clot. 

In spinal apoplexy the symptoms come on with absolute abrupt- 
ness. The cord is so small a body that a clot in its substance inter- 
rupts at once its function. The paralyses of motion and sensation 
are complete, and reflex movements are greatly exaggerated. As 
there is no correlation of the spinal nerve-roots, the spasms and pains 
of meningeal hemorrhage are wanting. 
6 



32 DIFFERENTIAL DIAGNOSIS. 

Acute primary myelitis is a very rare affection. The diagnosis 
should present no difficulty. The distinct febrile reaction, which is 
stated to be always present, separates it at once from all other acute 
affections of the cord proper, so that it can be confounded only with 
acute meningitis. Probably, in the majority of cases, it exists coin- 
cidently with the last disorder; but even when it is isolated, the 
symptoms at first closely simulate those of meningitis. 

In the slow, or chronic, forms of spinal disease, spinal tumors may 
be considered first. There are three classes of phenomena to be 
looked for in this disease : local symptoms of diseased structures ; 
atrocious pains at a distance from the seat of the disease, due to the 
involvement of nerve-roots and nerves, where they pass through the 
inflamed tissues ; and paralytic symptoms, the results of pressure, 
and to some extent of a local myelitis. In cases of suspected tumors 
of the spine, all these symptoms are to be looked for. In cancer, they 
are often all present, and the distant pains are especially remarkable 
for their atrocity. The symptoms of pressure are, of course, paralysis 
of motion and sensation gradually deepening. 

The other chronic spinal diseases may be classified with reference 
to the characteristic of tremors, as follows : 

Without tremors. With tremors. 

Sexual exhaustion. Paralysis agitans. 

White softening. Multiple sclerosis. 

^t . ,.,. (softening. 

Chrome myelitis. | sclerotic s 

Local myelitis. 

The difference between sexual exhaustion and myelitis is, probably, 
one of degree only ; but the former is curable ; the latter is not. 

White softening is very rare. If it can be distinguished clinically 
from myelitis, it must be by the complete absence, even in the begin- 
ning, of pain, and of spasm, and of heightened reflex activity, and the 
steady deterioration of the power of motion and of sensation, and of 
the other less distinct functions of the spinal marrow. 

Chronic « myelitis, with softening, is without, or almost so, the 
spasms, pains and heightened reflex movements, so common in the 
important form attended with 



DISEASES OF THE NERVOUS SYSTEM. 83 

SCLEROSIS OF THE CORD. 

This degeneration has been divided by writers into a number of 
clinical forms, of which the most important are (i) sclerosis of the 
antero-lateral columns, or sclerosis in patches (multi-locular sclerosis) ; 
and (2) sclerosis of the posterior columns (locomotor ataxy, tabes 
dorsalis). 

In sclerosis of the antero-lateral columns the attack usually begins in- 
sidiously; at first there is a loss of power or a trembling, or both, 
scarcely enough to attract the patient's attention. Generally one side 
is affected first, but soon the same is seen on the other side. There 
is usually no pain, no loss of sensation, no perverted sensation. Gen- 
erally at this stage there are no other symptoms than the weakness 
and trembling, unless there may be slight cerebral symptoms, as dizzi- 
ness, a sense of fullness or pressure, faintness, rarely headache. The 
trembling is peculiar ; when perfect rest can be attained it ceases ; but 
soon as an attempt is made to use a muscle the trembling begins 
again. An effort to carry a tumbler or a spoon to the mouth excites 
the trembling ; as soon as the object is laid aside, and the hand is 
placed quietly on the knees, there is rest again. The head requires 
for its support in the sitting posture the action of the muscles of the 
neck; hence when affected there is a constant oscillation of the head, 
unless the patient lies down. 

As the disease progresses the agitation may become excessive, as 
in some cases which have been reported wherein the agitation was so 
severe and violent as to shake the whole system with severe shocks 
when the least exertion was made, so that it was almost impossible to 
find a position, even lying down, in which there would not be more 
or less agitation. 

The weakness increases, and is one reason why the patient is una- 
ble to go about so much as formerly; walking soon tires him. The 
weakness may become so great as to be almost equal to a paralysis, 
only the least motion being possible; and when combined with con- 
traction, walking is out of the question. 

In sclerosis of the posterior columns the invasion is sometimes insidi- 
ous ; but generally the affection attracts the patient's attention very 



84 DIFFERENTIAL DIAGNOSIS. 

forcibly by the pain in the legs, which is frequently of a very severe 
type. This pain may be the only prominent symptom for years ; then 
may follow numbness, and at length the patient may learn accident- 
ally that he must use his eyes when walking, or he staggers. The 
pain is of a boring, throbbing, shooting character, suddenly darting 
through the leg or foot ; the patient's expressions show that the tor- 
ture caused thereby is extreme. 

The motor disturbances are characteristic. The patient is unable 
to walk or even to stand with his feet together with his eyes shut. 
In walking, the feet are raised with a jerk, higher than is necessary, 
are thrown forward or sideways in a disorderly way, and brought with 
the heels first forcibly to the ground. The attack is sometimes at- 
tended with a very violent form of gastralgia, or cardialgia, prone to 
recur at regular intervals. 

There are a number of distinctive differences between the symp- 
toms of these two affections. One usually begins in the arms ; the 
other in the legs ; one is without pain ; the other is accompanied with 
severe pain; in one there is trembling, muscular weakness, no inco- 
ordination ; in the other the reverse is noticed; in one slight or even 
severe cerebral symptoms occur ; in the other, with one exception, 
they are wanting. 

But sclerosis may not be confined strictly to the antero-lateral 
columns; the posterior columns also may become diseased, and then 
we may have a complicated case, in which will be found the symp- 
toms of both classes of cases. It is rare, however, for posterior 
sclerosis to spread to the lateral columns, and even when it does thus 
spread, it is only to a limited degree, and not to an extent sufficient 
to give rise to the symptoms of antero-lateral sclerosis. 

It may further be noted that, in chronic myelitis with softening, the 
paralysis is very marked, and the implication of the bladder and 
sphincter ani causes the patient to void his urine and feces involuntar- 
ily, which is not the case in locomotor ataxia. There is also absence 
of power in the legs, and none of the pain of ataxia. Ocular trouble 
and incoordination are likewise absent. In the gait of ataxia, the 
legs are thrown out with some degree of violence, and the heels come 
down forcibly ; in the paraplegia of myelitis the legs are dragged 



DISEASES OF THE NERVOUS SYSTEM. 85 

after each other, the inner sole scraping the ground. The steady pain 
in the back of myelitis is absent in ataxia (Hamilton). 

For the diagnosis of posterior sclerosis, Westphal has noted a 
symptom which may be thus described : If a healthy man sits with 
one knee-joint resting upon the other (a very common attitude), and 
the ligamentum patellae of the supported leg be smartly struck just 
below the knee-cap with the side of the hand, a sudden contraction 
takes place of the quadriceps femoris muscle (of which the ligamen- 
tum patellae represents the tendon), and the foot is consequently 
jerked upwards in a degree which varies in different individuals. 
Now in confirmed examples of locomotor ataxia this reaction does 
not take place. No matter on what part of the ligament below the 
knee-cap, or with what force the blow is struck, the foot hangs motion- 
less. In order to establish with accuracy the absence of the phenom- 
enon, certain precautions ought to be taken. The leg should be 
bare; the patient must not offer voluntary resistance to the move- 
ment of his leg, and the ligament should be struck with some hard 
implement which can be swung like a hammer. An ordinary wooden 
stethoscope answers very well if it is held loosely by the small end, 
and the blow given with the edge of the ear-piece. But, however 
administered, several blows should be struck on the ligament, slightly 
changing the position each time, as there is generally one spot from 
which the reaction is peculiarly energetic. This is usually a little 
below, but very near to, the patella. 

The tremor of cerebro-spinal sclerosis may be mistaken for that of 
paralysis agitans. Hamilton gives the following points of differ- 
ence : 

PARALYSIS AGITANS. j CEREBRO-SPINAL SCLEROSIS. 

Tremor continuous but not in- Tremor subsides during repose, and 
creased by voluntary effort. is always aggravated by volitional ef- 

j forts at control. 

Tremor regular and " fine." Tremor •'< coarse." 

Facial muscles not affected. Usually cranial nerve paralysis, or 

tremor of facial muscles. 



86 DIFFERENTIAL DIAGNOSIS. 

PARALYSIS AGITANS. CEREBRO-SPINAL SCLEROSIS. 

Runs forward to preserve balance. Only staggers when walking is at- 
tempted. 

Speech slow or affected by the vio- j Speech defects those which arise 
lence of muscular movements. < from paralysis. 

A disease of old age or advanced ! Usually a disease which appears 
life. I before middle life. 

REFLEX PARAPLEGIA AND PARAPLEGIA FROM 

MYELITIS. 

In reflex paraplegia the paralysis is incomplete ; there is no change 
in the appearance of the limbs ; no atrophy ; no impairment of the 
muscular contractility; no involvement of the sphincters (unless 
prior to the paralysis) ; no tendency to the formation of bed sores ; 
no alkalinity of the urine ; little or no sensory impairment, nor an- 
aesthesia. All these symptoms, on the other hand, are present in 
myelitis. In one word, the phenomena of reflex paraplegia have a 
superficiality which cannot escape close observation (J. K. Bauduy).* 

In the frequent cases where reflex paraplegia is due to irritation 
of the genito-urinary system, the differential diagnosis has been very 
clearly set forth by Dr. Brown Sequard in the following compara- 
tive table. f 

PARAPLEGIA. 

FROM URINARY REFLEX IRRI- FROM MYELITIS. 

TATION. 

i. Is preceded by an affection of! i. Usually no disease of the urin- 
bladder, kidneys or prostate gland. | ary organs except as consequent on 

I the paralysis 



2. Usually lower limbs alone par- i 2. Usually other parts paralyzed 
alyzed. i besides the lower limbs. 

3. No gradual extension of the par- 3. Most frequently a gradual ex- 
alysis upwards. tension of the paralysis upwards. 

* Lectures on Diseases of the Nervous System, p. 340. 

f Lectures on the Diagnosis and Treatment of Paraplegia, p. 33. 



FROM URINARY REFLEX IRRI- 
TATION. 

4. The paralysis is usually incom- 
plete, an extreme debility or weak- 
ness of the limbs rather than paraly- 
sis. 



5. Some muscles more paralyzed 
than others. 



6. Reflex power neither much in- 
creased nor completely lost. 

7. Bladder and rectum rarely par- 
alyzed : or at least only slightly so ; 
sphincter ani weak. 

8. Spasms in paralyzed muscles ex- 
tremely rare. 

9. Very rarely pains in the spine, 
either spontaneously or on applica- 
tion of pressure, percussion, or a hot, 
moist sponge, or ice. 

10. No feeling of pain or constric- 
tion around the abdomen or chest. 



it. No formication, pricking or 
disagreeable sensations of cold or 
heat. 

12. Anaesthesia rare, the tactile 
sensibility being but slightly, if at all, 
impaired; but the muscular sense is 
almost lost. 



DISEASES OF THE NERVOUS SYSTEM. 

FROM MYELITIS. 



87 



4. Very frequently the paralysis is 
complete. 



5. The degree of paralysis the same 
in the various muscles of the lower 
limbs. 

6. Reflex power often lost ; or 
sometimes much increased. 

7. Bladder and rectum usually com- 
pletely paralyzed or nearly so. 



8 Always spasms, or, at least, 
twitchings. 

9. Always some degree of pain 
existing spontaneously, or caused by 
external excitations. 



10. Usually a feeling as if a cord 
were tied tightly around the body at 
the upper limit of the paralysis. 

11. Always formications, or prick- 
ing, or both, and very often sensa- 
tions of pricking or heat or cold. 

12 Anaesthesia very frequent and 
always at least numbness. 



13. Usually obstinate gastric de- 13. Gastric digestion good, unless 
rangement. t the myelitis has extended high up in 

! cord 

14. Variations in the degree of the j 14 Ameliorations very rare, and 
paralysis corresponding with changes [ not following changes in the condi- 
in the primary disease. i tion of the urinary organs. 



DIFFERENTIAL DIAGNOSIS. 



FROM URINARY REFLEX IRRI- 
TATION. 

15. Usually the urine is acid, un- 
less the urinary organs are diseased. 

16. Cure of the paralysis frequently 
and rapidly obtained, or taking place 
spontaneously after a notable amelior- 
ation or cure of the urinary affection. 

17. Usually muscles do not become 
atrophied, and temperature is little 
lowered. 



FROM MYELITIS. 
15. Urine almost always alkaline 



16. Frequently a slow and gradual 
progress towards a fatal issue, and 
rarely a complete cure. 



17. Atrophy of muscles of the 
paralyzed parts. 



GENERAL PARALYSIS OF THE INSANE. 

•This curious disease, long unknown in the United States, has of 
recent years been frequently observed in the Northern and Eastern 
States, but so far, rarely or not at all in the South and West. It is a 
disease of advanced life, whose pathognomonic characteristics are con- 
stant troubles of motility, a progressive loss of mental power, and a 
constant belief on the part of the patient that he is perfectly well, and 
in the enjoyment of magnificent fortune and gigantic powers [delircs 
des grandeurs). 

The following are the progressive traits of the disease as generally 
observed : 

PSYCHICAL SYMPTOMS. 

1. General restlessness and unsteadiness of mind, with impairment 
of attention; alternating with apathy and drowsiness. 

2. A change in disposition and temper, and a general loss of self- 
restraint ; at first as regards trivial, social observances, and then as 
regards general conduct. 

3. Impairment of the reflective powers, so that there is no logical 
and systematic development of thought. 

4. General exaltation of thought, with a profusion of remembered 
images and ideas, and numerous extravagant desires. 

5. Failure of memory and forgetfulness ; at first of words, and then 
of events. 

6. Delirious conceptions, and the transformation of desires into be- 



DISEASES OF THE NERVOUS SYSTEM. 89 

liefs, these being generally connected with personal greatness and 
power. 

7. Hallucinations of the senses, in which remembered sense impres- 
sions are so vivid and intense as to spread to the periphery. 

8. Maniacal restlessness and excitement, in which present impulses 
and feelings instantly pass over into action. 

9. Increased mental weakness, with the incoherent and fragmentary 
repetition of the false ideas previously entertained. 

10. Failure of the senses, with more marked impairment of memory. 

1 1. Complete fatuity, passing into coma and death. 

MOTOR SYMPTOMS. 

1. Persistent contraction of the occipito frontalis muscle, and some 
dilatation of pupils, causing the eyes to be widely opened and the fore- 
head wrinkled, and giving an expression of surprised attention to the 
face. 

2. Persistent contraction and frequent tremors of the zygomatic 
muscles, giving a pleased and benevolent expression of countenance. 

3. Slight muscular restlessness and unsteadiness. 

4. Impairment of the power of executing fine and detailed move- 
ments, so that manipulative skill is lost while movements en masse are 
still well performed. 

5. Fibrillar tremors of the tongue, and some loss of control over its 
movements, so that it is protruded with difficulty ; is rolled about 
when protruded, and is suddenly withdrawn. 

6. Twitchings of the nostrils and upper lip, with frequent tremors 
of the latter. 

7. Impairment of articulation, which is thick, and wanting in dis- 
tinctness. 

8. An alteration in the voice, as well as thickness and hesitancy in 
speech. 

9. Loss of control over the combined movements of the hand and 
wrist, so that the hand-writing generally deteriorates. 

10. Changes in the pupils, which are at first irregularly contracted, 
and then become irregularly dilated. 

1 1. An alteration in gait, which becomes unsteady ; the more com 



90 DIFFERENTIAL DIAGNOSIS. 

plex movements of the thighs, leg, and foot, and the balancing of the 
the pelvis on the hip joints, being performed with difficulty. 

12. General muscular agitation and restlessness. 

13. Gradual loss of power in the muscles of the face, tongue, neck, 
and limbs. 

14. Spasmodic contraction of the masseter muscles, causing grind- 
ing of the teeth. 

15. Convulsive seizures — most marked on one side of the body, and 
followed by transitory hemiplegia. 

16. Loss of control over the sphincters. 

17. Complete prostration of muscular strength and helplessness, 
and difficult deglutition. 

18. Contractions of the muscles of the limbs, and paralysis of the 
muscles of respiration. 

The main diagnostic difficulty is to distinguish this from some 
phases of locomotor ataxy. The differences are that in general paraly- 
sis the mental symptoms are always present, and always precede the 
motor phenomena. The first symptoms in general paralysis are 
chiefly cerebral ; viz., mental excitement, great garrulity, noisy hilarity, 
bragging, early violence of behavior, and very usually some exhibition 
of libidinous conduct; on the subsidence of excitement, the mind is 
found to be weak, and the motor phenomena gradually make their 
appearance. 

In ataxia, the commencement is in the spinal functions. There is 
first an attack of pain of some remote part, occurring most frequently 
in the lower extremities, and dating several years back, considered at 
the time perhaps to be rheumatic; this pain is worse towards evening, 
or when the patient is not mentally occupied ; it may improve or dis- 
appear for a time and return. Then follows a slight degree of numb- 
ness of the part ; the patient feels as if he trod on wool ; occasionally 
"pins and needles" attack the part; in fact, those phenomena which 
we have all experienced after sitting in an awkward position, when 
one's own leg has " gone to sleep." There is, as most of us know, 
want of feeling, want of recognition of the member, especially as to 
its size, and even its ownership, then atrocious pain, and pins and 
needles. In the disease, on the subsidence of the pain, the patients 






DISEASES OF THE NERVOUS SYSTEM. 



91 



exhibit some awkwardness in gait; the ataxy or want of order on 
the movement is evident. These symptoms may extend over ten or 
twelve years with very little change, except, perhaps, increasing awk- 
wardness in gait ; there is doubtless some numbness of the cutaneous 
surface in the course of the disease ; the phenomena appear to spread 
upwards by involving the functions of the nerves higher up; the erec- 
tion of the penis, and soon afterwards the sexual appetite, are lost, 
and the disease ascends ; the expulsory power of the bladder and 
rectum become impaired. All this occurs while little change takes 
place in the mental functions ; but in other cases the mind appears 
imbecile, the memory is affected, and there is distinct alteration in 
behavior and conduct ; but there are no lofty ideas, no excessive 
excitement and garrulity, and in no case paroxysms of violence or 
libidinous ideas. 

The differences may be better seen in a tabulated form : 



GENERAL PARALYSIS. 
Runs its course in a few years. 

Commences with mental symptoms. 

Is attended with libidinous ideas. 



LOCOMOTOR ATAXY. 

Is much slower usually, and may 
last ten or even twenty years. 

Commences with pain in a distal 
nerve. 

Is attended with absence of sexual 
feeling: 



The motor symptoms are secondary i The motor symptoms are the pri- 
in the order of time. 1 mary phenomena. 



Is only rarely complicated with 
pelvic difficulties. 

There often is great violence. 



Pelvic symptoms are a prominent 

feature 

The mental phenomena are imbe- 
i cility and impaired memory. 



There is also a form of general paralysis due to syphilis. The 
differential features of this variety have been clearly defined by 
Dr. E. C. Seguin.* We do not obtain the regular gradations and 
stages of the true disease. The moral perversion which is peculiar 



Hospital Gazette. Sept., 1878. 



9 2 



DIFFERENTIAL DIAGNOSIS. 



to general paralysis is absent, neither do we see the pure exalted 
notions. The fibrillary tremors that are so well marked in general 
paralysis are not present here. The articulation is more mumbling 
in character. We, likewise, are apt to have a great deal of actual 
paralysis of cranial nerves or body in these cases. In true general 
paralysis, after attacks of hemiplegia, the patient regains his full 
strength, whereas this is not apt to occur in the syphilitic variety. 
The following table will perhaps show clearly the main differences : 



SYPHILITIC GENERAL 
PARALYSIS. 

Absent. 

Rare or absent. 



Speech is thick. 

Absent as a rule. 

Paresis or actual paralysis. 

Apt to be open or wide. 

Palsy of third or of other cranial 
nerves. 

Headache nocturnal. 

More serious aphasic attacks. 



TRUE GENERAL PARALYSIS. 

Prodromic stage. 

Exalted notions, numerous and 
varied, and relatively exalted accord- 
ing to the position in life. 

Speech is tremulous and jerky. 

Tremor of hands and lips. 

Preservation of strength. 

Pupils are apt to be contracted. 

None. 

None. 

Transient aphasic attacks. 



Progressive except under treatment. ' Spontaneous remissions. 

Some other differences between the two conditions are as follows : 
The patient with syphilis has none of the cravings or abnormal appe- 
tites of the other; the latter feels an impulse to get drunk or to have 
an excess of coition. The tendency to excessive coition is absent in 
syphilitic paralysis, and indeed there is a marked loss of the virile 
power. The temperature changes are also absent in syphilis of the 
brain. The rise in temperature in general paralysis of the insane is 
very great, often reaching 103 in exacerbations. There is no rise of 



DISEASES OF THE NERVOUS SYSTEM. 93 

temperature in syphilis of the brain except, perhaps, when the patient 
has hemiplegia from a large lesion. 

The most important point is, that in syphilis, there is a paralysis ; 
in general paralysis there is irritation and incoordination without 
true paralysis. 

PSEUDOHYPERTROPHIC PARALYSIS. 

This is a disease of children, usually attacking them in the second 
year of life. At that period it is found that when they are placed 
upon their feet, they fall down, or clutch at the nearest object to sup- 
port themselves ; or in other cases it may be that the child has com- 
menced to walk, when without pain or fever, or sometimes after con- 
vulsions, it is found to be soon fatigued, either by walking or standing, 
and at length it can no longer walk or hold itself upright ; or, again, 
it may be that the child does not walk until very late, 2j^ or 3 years, 
and then very feebly and imperfectly. 

Symptoms. — The principal morbid phenomena are, as Dr. Duchenne 
gives them — 

1st. In the beginning, feebleness of the lower limbs. 
2d. Lateral balancings of the trunk and widening of the legs during 
walking. 

3d. A peculiar curvature of the spine (ensellure), or saddle-back 
(lordosis), both in walking and standing. 

4th. Equinism (talipes equinus), with a peculiar over-extension of 
the first phalanges of the toes, which Duchenne calls " griffe des 
orteils." 

5th. Apparent muscular hypertrophy. 
6th. Stationary condition. 

7th. Generalization and aggravation of the paralysis. 
When the disease has arrived at the stage of apparent hypertrophy, 
the appearance of the patient is very characteristic, and its true nature 
would be at once obvious to any one who had any knowledge of its 
symptoms ; but in the earlier stages there is but little to guide us to a 
diagnosis unless we have some hereditary history. Of the hereditary 
nature of this affection the published cases give ample proof. 



94 DIFFERENTIAL DIAGNOSIS. 

PARALYSIS FROM LEAD POISONING. 

In this form of paralysis the usual diagnostic symptoms, to wit, a 
history of exposure to lead, the blue line on the gums, constipation 
and colic, may all be absent; hence the diagnosis must rest upon the 
peculiar characters of the palsy — especially the effects of electric cur- 
rents upon the muscles. These are the only reliable evidences of the 
nature of the disease. These characteristic reactions, first described 
by Duchenne, are as follows : 

Excitability to Faradaism absent or sensibly diminished in all the 
muscles of the forearm except the supinators longus and brevis. In 
health the supinator brevis can not be directly Faradized on account 
of its deep position. But in lead palsy it very often happens that the 
wasting of the extensor communis digitorum has proceeded far enough 
to uncover the supinator brevis sufficiently to allow a small reophore 
to be applied to it in the space of about a square inch at the upper 
and back part of the forearm. If it be found (both arms being affected) 
that the common extensor fails to respond to Faradaism whilst the 
short supinator close by, on a lower plane, is readily excited by it, the 
case may be positively set down as one of lead palsy. 

NEURALGIA. 

The positive signs which distinguish a case of pain to belong to 
the neuralgise are succinctly set forth by Dr. Francis E. Anstie* 
as follows : 

(i) The first and most essential characteristic of a true neuralgia 
is that the pain is invariably either frankly intermittent, or at least 
fluctuates greatly in severity, without any sufficient and recognizable 
cause for these changes. 

(2) The severity of the pain is altogether out of proportion to the 
general constitutional disturbance. 

(3) True neuralgic pain is limited with more or less distinctness to 
a branch or branches of particular nerves ; in the immense majority 
of cases it is unilateral, but when bilateral it is nearly always sym- 
metrical as to the main nerve affected, though a larger number of 

* Neziralgia and its Counterfeits, p. 565. 



DISEASES OF THE NERVOUS SYSTEM. 



95 



peripheral branches may be more painful on one side than on the 
other. 

(4) The pains are invariably aggravated by fatigue or other de- 
pressing physical or psychical agencies. 

These four cardinal points of the diagnosis may be further sup- 
ported by the history of the patient. Either (1) he has previously 
been neuralgic, or liable to other neuroses, or comes of a neurotic 
family ; or (2) there has been malarial poisoning of the blood; or (3) 
there has been some long continued peripheral or central irritation ; 
or (4) finally, there has been constitutional syphilis. 

The pains with which neuralgia is most likely to be confounded 
are those arising from myalgia, spinal irritation, locomotor ataxia, cere- 
bral abscess, alcoholism, syphilis, chronic rheumatism, and latent gout. 

In comparing the pains of myalgia and neuralgia the following are 
the more imortant points : 



NEURALGIA. 

Follows the distribution of a recog- 
nizable nerve or nerves. 



MYALGIA. 

Attacks a limited patch or patches 
that can be identified with the tendon 
or aponeurosis of a muscle which, on 
inquiry, will be found to have been 
hard worked. 



Accompanies an inherited or ac- ! Often occurs in persons with 
quired nervous temperament which is : special neurotic tendency, 
obvious. 



no 



Is usually not much or at all aggra- 
vated by movement. 



Is inevitably and very severely ag- 
gravated by every movement of the 
part. 



Is at first not accompanied by local Distinguished from the first by lo- 
tenderness. calized tenderness on pressure as well 



as on movement. 



Painful points, when established in , Tender points correspond to tendi- 
a later stage, correspond to the emerg- nous insertions and origins of muscles, 
ence of nerves. 



Pain not materially relieved by any Pain usually completely and always 
change of posture. ! considerably relieved by full extension 

of the painful muscle or muscles. 



9 6 



DIFFERENTIAL DIAGNOSIS. 



Treatment also offers a diagnostic means. The pains of myalgia 
will ordinarily disappear at once by retaining the affected muscle at 
full extension, surrounding it with moist warmth, and giving 20 or 
30 grains of muriate of ammonia internally. 

Spinal Irritation (spinal congestion or spinal anaemia) is almost ex- 
clusively confined to women. There are nearly always hysterical 
symptoms, marked superficial tenderness over large portions of the 
surface, often merely cutaneous and becoming less acute with firm 
pressure. There are nearly always tender spots along the spine, and 
also over the epigastrium and the left hypochondrium. 

Locomotor ataxia is mentioned elsewhere, and its symptoms de- 
scribed in sufficient detail. (See the Index.) 

Cerebral abscess, though rare, may give rise to a regrettable mistake, 
especially in its early stages, where severe pain in the head is almost 
the only conspicuous symptom. At this period the diagnosis from 
neuralgia must rest on the following points of contrast : 



CEREBRAL ABSCESS. 
Often occurs secondarily to caries 
of internal ear, and purulent dis- 
charges, the result of scarlet fever, 
measles, etc., in childhood. 

Frequently follows a blow or in- 
jury. 



NEURALGIA OF THE HEAD. 

Rarely appears before puberty. 



Comparatively seldom caused by a 
blow or other external injury, or car- 
ies of the bone. 



No true " points douloureux." 

Usually the pain does not com- 
pletely intermit. 

Pain often excruciating from a very 
early period. 

Pain often limited in situation, 
seems deep-seated, though as often 
as not it has no relation to the site 
of the abscess. 



If severe, soon presents, in most 
I cases, the points douloureux. 

Intermissions of pain complete and 
of considerable length. 

Pain usually not very violent at 
first. 

Pain superficial ; follows distribu- 
tion of recognizable nerve branches 
belonging to the trigeminus or great 
occipital. 



DISEASES OF THE NERVOUS SYSTEM. 



97 



CEREBRAL ABSCESS. 
No well localized vaso-motor or 
secretory complications. 

Very rare in old age ; then usually 
traumatic. 

Relief from stimulant narcotics very 
transitory. 



NEURALGIA OF THE HEAD. 

Usually lachrymation, or conges- 
tion of the conjunctiva, etc. 

Severe neuralgia is commonest in 
! advanced life. 

Relief, from opium, etc., is much 
more considerable and permanent. 



The pains of chronic alcoholism often closely simulate those of true 
neuralgia. The habits and history of the patient, when known, point 
to the true origin of the suffering ; also the insomnia, loss of appe- 
tite, foul breath, furred tongue and haggard countenance of the 
drunkard ; and especially that the pains complained of encircle the 
limbs Jiear the joints, rather than run longitudinally the course of the 
nerves in the limb, are all significant. 

The osteocopic pains of syphilis are usually symmetrical ; are ag- 
gravated by the warmth of the bed ; are generally referred to the 
superficial bones, and do not exist long without some other and de- 
cisive symptoms of the poison manifesting themselves. 

Chronic rheumatism and gout are each attended with such marked 
collateral disturbances that the suspicion of their presence can readily 
be set at rest or sustained. 

SPINAL IRRITATION. 

This affection has been described by some writers as spinal hyper 
aemia, by others as spinal ansemia; again as spasms of the spinal 
muscles, and lastly as abnormality of the spinal cells. Some have 
denied its existence altogether; but in fact it is a distinctly defined 
and not unusual disorder. About five-sixths of the cases are females 
and it is often associated with uterine or ovarian disease ; and as 
often has some antecedent history of a blow upon or other slight 
injury to the spine. 

Its symptoms are of the most varied kind, so much that it may 

simulate almost every known ailment ; but a careful examination oj 

the spine will reveal its true character. The diagnostic rules laid 

down by Drs. William and David Griffin, in 1834, who first de- 

7 



98 DIFFERENTIAL DIAGNOSIS. 

scribed the disease, have never been improved upon. They are as 
follows : 

1. The pain or disorder of any particular organ complained of, is 
altogether out of proportion to the constitutional disturbance. 

2. The complaints, whatever they may be, are usually relieved by 
the recumbent position, are always increased by lifting weights, bend- 
ing, stooping, or twisting the spine ; and, among the poorer classes, 
are often consequent to the labor of carrying heavy loads, drawing 
water, etc. 

3. The existence of tenderness at that point of the spine which 
corresponds to the disordered organ, and the increase of pain in that 
organ by pressure on the corresponding region of the spine. 

4. The disposition to a sudden transference of the diseased action 
from one organ or part to another, or the occurrence of hysterical 
symptoms in affections apparently acute. 

5. The occurrence of continued fits of yawning or sneezing. These 
are not very common in the disease ; but when they do occur, they 
may generally be considered as characteristic of nervous irritation.* 

To this it may be added that the tenderness may extend along the 
spine generally ; but is always greater in one or two spots. Gastric 
symptoms, headache and languor are usually well marked in spinal 
irritation; but there is neither atrophy, paralysis (except hysterical) 
nor waist constriction, which serve to distinguish it from a large 
class of spinal diseases. 

HYSTERIA. 

Few diseases present at times greater difficulties to diagnosis than 
this protean complaint. Its countefeits of various maladies will be 
considered elsewhere (see the Index) ; at present we shall seek for a 
pathognomonic symptom of the general condition. 

One is offered by Dr. Thomas BARLOW.f Rejecting as unsatisfac- 
tory all statements depending upon the patient's veracity, he finds a 
diagnostic test in the presence of analgesia. If, while the patients 

* Functional Affections of the Spinal Cord ; quoted by Dr. McCall Anderson. 
j Med, Times and Gazette, Feb., 1878. 



DISEASES OF THE NERVOUS SYSTEM. 



99 



attention is directed to something else, a needle be introduced into the 
forearm and no wincing occurs, there is the strongest presumption 
that we have to do with a case of hysteria. Again, it has been long 
known that hysterical patients are often extremely tolerant of laryn- 
goscopy examination. Great advantage will be found in examining a 
presumed hysterical patient's larynx, and thus fixing her attention 
whilst somebody at the same time inserts a needle into her forearm. 
Absolute tolerance of these two simple methods of examination is 
quite decisive. 

Another characteristic relates to the pain so frequently complained 
of. While it is stated to be exceedingly acute, and the part tender to 
the slightest pressure, if the attention of the patient is engaged, very 
firm pressure may be made without the patient wincing. Moreover, 
there is noted very often a co-existence of severe pain in the epigas- 
trium, the left side and spinal column — the trepied hysterique, or hys- 
terical tripod of French authors. 

The globus hystericus, a sensation of a foreign body in the throat 
caused by spasmodic contraction of its muscles, is a common symp- 
tom. The urine may be suppressed, or may be limpid and watery, 
and of unusual quantity. 

If with these traits are united youth and female sex ; ovarian or 
uterine disturbance ; the general symptoms harmonious and exagger- 
ated ; the mind clear ; and the disappearance of contractions, etc., 
under anaesthesia ; the diagnosis is complete. 

The most serious mistake would be the confounding of a hysterical 
paroxysm with an epileptic fit. The following table of distinctions 
between the two is given after Charcot and Da Costa : 



EPILEPSY. 

Sudden and complete loss of con- 
sciousness. 

Livid face ; escape of frothy saliva 
from the mouth ; eyelids half open ; 
eye-balls rolling; grinding of the 
teeth ; biting of the tongue ; more or 
less insensibility of the pupils to light. 



HYSTERIA OR HYSTERO- 
EPILEPSY. 
Gradual or only partial or apparent 
unconsciousness. 

Face flushed or complexion unal- 
tered ; no froth on lips ; eyelids 
closed ; eyeballs fixed ; neither grind- 
ing of the teeth nor biting of the 
tongue ; pupils react readily. 



IOO 

EPILEPSY. 

Distortion of countenance. 
Patient evinces no feeling. 
Aura epileptica of short duration. 



Convulsions often more marked on 
one side than on the other ; and more 
tonic than clonic. Agitation mani- 
acal and disorderly. 

Paroxysm generally of short dura- 
tion. 



DIFFERENTIAL DIAGNOSIS. 



HYSTERIA OR HYSTERO- 
EPILEPSY. 

No distortion of countenance. 

Patient sighs, or laughs, or sobs. 

Aura often prolonged one or two 
days. Globus hystericus. 

No such differences; convulsions 
clonic. Agitation emotional, often 
en pose. 



Paroxysms generally of longer du- 
ration. 



Paroxysm followed by a heavy, half 1 Paroxysm not followed specially by 
comatose sleep, by headache, and I sleep; patient often, after attack, wake - 
dullness of intellect. Stertor. No hal- j ful and depressed in spirits. Little or 
lucinations. ! no stertor. Hallucinations. 

Frequently occurs at night. Rarely occurs at night. 

No particular connection with uter- Often connected with disorders of 
ine disturbance; although a parox- ! the uterus, or of menstruation, 
ysm often takes takes place at the men- 
strual period. 

Hysterical Paralysis, in spite of its frequent close imitation of the 
organic forms, is readily diagnosed by attention to the following 
points : • 

1. In hysterical hemiparesis the face is rarely, and the tongue 
never, affected. 

2. In hysterical paraplegia incontinence of urine is never present. 
(Hamilton.) • 

3. No amount of help can keep the patient from staggering or fall- 
ing when she attempts to walk. (Reynolds.) 

4. The foot in walking is simply dragged along and not swung as 
in organic hemiplegia. (Todd). 

5. In all sudden cerebral palsies, the nails of the affected extrem- 
ties cease to grow. In hysterical palsies, of one limb or both, 



DISEASES OF THE NERVOUS SYSTEM. IOI 

whether paraplegic or hemiplegic, the rate of nail growth is unal- 
tered. (Weir Mitchell.) 

INSANITY. 

The treatment of the insane is now almost confined to institutions 
for the purpose, but the detection of its earlier phases must always 
remain part of the duty of the general practitioner. 

Insanity is divided into two forms, mania and melancholia, their 
general distinctions, as defined by Dr. E. C. Seguin, being as follows : 



MANIA. 

Ezo elated and over active. 



MELANCHOLIA. 

Ego is depressed and does not re- 
act normally on external world. 



Joy and excitement generally pre- Sadness and fear; religious feelings 
vail, sometimes comic emotions char- strongly developed, 
acterize attacks. 



Over-ideation and over-action. Re- 
sulting therefrom incoherence and de- 
lirium and violent acts ; general rest- 
lessness. 



Insomnia. 



Reduced ideation. 



Reduced action. 



( few motions and 
-< even absolute 
(silence. 

Immobility rel- 
ative or total and 
") even cataleptoid 
[state. 



Insomnia (less marked). 



Increased circulation. 
Increased calorification. 



PHYSICAL SYMPTOMS. 

Lessened circulation. 
Lessened calorification. 
Lessened assimilation. 



Increased (?) assimilation. 
Increased voracity. 

The earliest symptoms of insanity are a marked change in the hab- 
its ; proneness to excitement and loss of control ; an alteration in the 
emotions; failure of memory; untidiness of dress ; insomnia and dis- 
turbing dreams; unusual loquacity or taciturnity; defective reasoning; 



102 



DIFFERENTIAL DIAGNOSIS. 



accepting as real various fancies and illusions ; a furtive, watchful air ; 
groundless suspicions of those around. In combination with these 
mental symptoms there are often dilation of the pupils, frequently 
irregular, and sluggish in obeying the stimulus of light ; and a pulse 
hard, rapid and variable, 1 00 or over, and the pulse not equal in both 
wrists (Henry Howard). The tongue is pasty, the breath foul, and 
the bowels constipated. The digestion is impaired, and the appetite 
irregular and capricious. 



CHAPTER II. 
DISEASES 

OF 

THE RESPIRATORY SYSTEM. ' 

Diseases of the Larynx. — Symptoms of Laryngeal Diseases. Diag- 
nostic table of Acute Laryngitis, Chronic Laryngitis, Syphilitic Laryn- 
gitis, Tubercular Laryngitis, Prcichondritis , Benign Growths, Malig- 
nant Growths , and Neuroses of the Larynx. Croup and Diphtheria ; 
Spasmodic Croup, Inflammatory Croup, Membranous Croup, and 
Diphtheria. Tonsillitis, Catarrhal and Parenchymatous. 

Diseases of the Lungs. — The Regions of the Chest. Normal Differ- 
ences between the two sides of the Chest. Methods of Physical 
Examination. Normal Respiratory Sounds. Normal Voice Sounds. 
Abnormal Percussion Sounds. Abnormal Respiratory Sounds. Ab- 
normal Voice Sounds. General Rules for Diagnosis. The Forms of 
Phthisis [Catarrhal, Fibroid, Tubercular). The Diagnosis of Incipient 
Phthisis. Diagnosis between Incipient Phthisis and Bronchitis. Clin- 
ical History of Phthisis. Acute Phthisis. Syphilitic Phthisis. Bron- 
chitis t Acute and Chronic. Capillary Bronchitis compared with 
Pneumonia. Pneumonia and Pleurisy. Pleurisy with Effusion and 
Pneumonia with Consolidation compared. Diagnosis between Pneu- 
monia and Pulmonary Apoplexy. Pulmonary Embolism. Asthma. 
Pneumo-thorax and Pncumo-hydrothorax. Emphysema, Vesicular 
and Interlobular. Cancer of the Lung. 

The diseases of the respiratory organs include those of the larynx 
and lungs. We commence with : 

(103) 



104 



DIFFERENTIAL DIAGNOSIS. 

DISEASES OF THE LARYNX. 



The general symptoms of laryngeal diseases, together with their 
causes and examples, may be arranged in the following tabular form : 

SYMPTOMS OF LARYNGEAL DISEASES. 



Symptoms. 



Cause. 



Dysphonia. Alteration in the vocal cords 
from thickening ulceration, 
diminished tension, morbid 
growths, etc. 



Aphonia, 



Dyspnoea. 



Stridor. 



Cough. 



Non-approximation of the vo- 
cal cords, either mechanical 
or due to paralysis of some 
of the muscles attached to 
them. 



Narrowing of the orifice of the 
glottis. 



Examples of Disease. 



Acute and chronic laryngitis. 
Laryngeal phthisis. 
Papillomata, etc. 



Cicatrization. 

Swelling of arytenoid carti- 
lages. 

Tumors. 

Hysteria. 

Pressure on recurrent laryn- 
geal nerves, etc. 

Paralysis of muscles opening 
glottis. 

Laryngismus stridulus. 

CEdema, growths and cica- 
trices contracting rima glot- 
tidis, and pressure external 
to larynx. 



Always accompanied by dys-iAs in Dyspnoea, 
pnoea, and produced by the 



same causes. 



Irritation of the laryngeal 
mucous membrane, or the 
nerves of the larynx. 



In most laryngeal diseases, it 
is of a peculiar shrill, brazen 
character. 



In the study of laryngeal diseases the use of the laryngoscope is 
indispensable to correctness of diagnosis. We take it for granted 
that the practitioner is conversant with this instrument, and the 
proper methods of employing it. It reveals the physical or object- 



DISEASES OF THE RESPIRATORY SYSTEM. 105 

ive local symptoms, which are of much more value than the subject- 
ive ones derived from the patient's statements. 

Laryngitis has been divided by some writers into the following 
forms : 

(Edematous laryngitis. 

Catarrhal laryngitis. 

Erysipelatous laryngitis. 

Croupous laryngitis. 

Diphtheritic laryngitis. 

Syphilitic laryngitis. 

Tubercular laryngitis. 

Exanthematous laryngitis. 

Traumatic laryngitis. 

For the present we will adopt the classification proposed by Mr. 
Lennox Browne, of London, who in his recent work on the Diseases 
of the Larynx gives the diagnostic table presented in the following 
pages. 



io6 



DIFFERENTIAL DIAGNOSIS. 



Symptoms. 

A. — Function 

Voice. 



Respiration. 



Cough. 



Deglutition. 



Pain and Al 
tered Sensa- 
tion. 

B. — Physical 

Color. 



Acute Laryngitis. 



al or Subjunctive. 

Hoarse, becoming aphonic. 



Not embarrassed prior to 
oedema ; then stridor, dys- 
pnoea, and even apnoea. 

Dry, hard, shrill, metallic ; 
aphonic ; on exudation, 
moist. 

Painful when oedema has 
taken place, or from asso 
ciated pharyngeal inflam- 
mation. 

Sensation of tightness and 
constriction ; tender to 
external pressure. 

or Objective. 

Intense, uniformly increas- 
ing superficial hyperaemia ; 
translucent on advent of 
oedema. 



Form and Text- Thickening and stenosis from 
ure. oedema, loss of tissue rare, 

except in phlegmonous 
form. 



Chronic Laryngitis. 



Hoarse, uncertain, easily fa- 
tigued. 

Seldom embarrassed. 



Irritation, with slight expec- 
toration of glutinous pel- 
lets. 



Position. 



Unaltered. 



C. — Miscella neous. 

External. 



Rarely affected. 



Painless; sense of fatigue 
after vocal exercise. 



Partial and modified submu- 
cous hypersemia. 



Occasionally slight erosion, 
never ulceration, thicken- 
ing or narrowing. 



Unaltered. 



Pharynx usually synchro- Pharynx usually synchro- 
nously implicated. nousl y implicated. 




DISEASES OF THE RESPIRATORY SYSTEM. 



107 



Syphilitic Laryngitis. 



Sec y . Hoarse. 

Tert y . Characteristically raucous ; sel- 
dom aphonic. 

See*. Unchanged. 

Tert y . Increasing embarrassment ac- 
cording to amount of stenosis. 

Sec y . Slight hacking. 

TerP. Infrequent, with but slight ex- 
pectoration, unless perichondritis 
supervene. 

Sec y . Normal, unless deposit on epi- 
glottis or arytenoids. 

Terty. Often difficult ; very rarely 
painful. 

Characteristic absence of pain ex- 
cept when cartilages are attacked. 



Secy. Mottled, more or less symmetri- 
cal hyperaemia. 

Tert y . Hyperaemia of portion attacked 
prior to ulceration : permanent in- 
filtrated appearance. 

Sec y . Occasional superficial ulceration 
at vocal process ; slight general sub- 
mucous infiltration. 

Tert y . Deep, circumscribed destructive 
ulcers, of yellowish color, followed by 
cicatricial narrowing, occasionally 
paralysis and quasi-new formations. 

Sec y , Unaltered. 

Tert y . Deformity from intrinsic cica- 
trices and pharyngeal outgrowths. 

Sec y . Pharynx and skin generally re 
cently implicated. 

Tert y . Seldom synchronous implica- 
tion, but usually scars of previous 
similar pharyngeal ulceration, and 
possible adhesion. 



Tubercular Laryngitis. 



Sometimes aphonic in earlier stages ; 
completely lost in advanced dis- 
ease. 

Early hurried ; greatly embarrassed 
with advance of disease. 

Greatly influenced by amount of lung 

disease ; painful. 
Expectoration variable ; generally 

frothy. 

Extremely difficult and painful, from 
early period to termination. 



Pain only experienced in functional 
acts. 



Anaemia followed by opaque grayish 
color ; margins of ulcers hyperae- 



Solid submucous thickening of epi- 
glottis and ary-epiglottic folds, ele- 
vation and ulceration of racemose 
glands giving worm eaten ulcers, 
which commingle and attack deeper 
tissues. 

No displacement ; tendency for thick- 
ened parts to transgress boundaries 
of pharynx. 

Lungs either primarily, synchro- 
nously, or subsequently involved. 
Generally anaemia, rarely ulcera- 
tion of pharynx. General emacia- 
tion. 



io8 



DIFFERENTIAL DIAGNOSIS. 



Symptoms. 



A. — Function 

Voice. 



Respiration. 



Cough. 



Deglutition. 



Patn and Al- 
tered sensa- 
tion. 

B. — Physical 

Color. 



Fofm and Tx- 

T UR. 



Position. 



C. — Miscella 

External. 



Perichondritis. 



al or Subjective. 

Painful, easily fatigued, but 
not necessarily impaired. 



Variable, according to carti- 
lage attacked. 



Generally early spasmodic ; 

with caries characteristic. 
Purulent expectoration, unless 

abscess is encysted. 

Varying from dysphagia to 
aphagia, according to pres- 
sure on gullet. 

Pain variable with cause; most 
severe in gouty form, but 
not then constant. 

or Objective. 

Hypersemia generally limited 
to porton attacked, some- 
times extending to con- 
tiguous vocal cord. 

Ulceration often absent, sub- 
stituted by encysted ab- 
scess, causing narrowing, 
compression and paralysis. 



May be considerable altera- 
tion of supra and infra- 
glottic space. 

neous. 

Occasional constitutional 
manifestations. 



Benign Growths. 



Very variable, from slight: 
hoarseness to complete | 
aphonia, even in the samej 
case. 

Seriously embarrassed in one-! 
sixth of cases ; depends on' 
situation. 

Generally limited to effort to 
dislodge foreign body ; 
may be expectoration of 
atoms of growth. 

Only impaired in rare cases, 
in which epiglottis or ary- 
epigiottic fold is involved. 

Characteristically absent. 



Variable with nature of neo- 
plasm ; slightly increased 
vascularity of mucosa gen- 
erally. 

Varies with situation, size, 
and nature of growth, never 
ulceration. May cause 
narrowing and paralysis. 



Position of normal parts sel- 
dom changed. 



Nil. 






DISEASES OF THE RESPIRATORY SYSTEM. 



IO9 



Malignant Growths. 



Impaired by mechanical causes when 
invaded from pharynx ; may be 
early lost in primary disease. 



Early quickened on exertion; later 
paroxysmal dyspnoea from stenosis 
or compression. 

Not necessarily present ; expectoration 
scanty ; occasionally blood and por- 
tions of neoplasm. 



Always difficult and painful 
earliest symptom. 



often the 



Neuroses. 



extending 



Ever present and severe 

upwards to the ears, and to sympa 
thetic glandular enlargements. 



Lost in bilateral paralysis of adduc- 
tors ; impaired in other paralyses ; 
not necessarily in spasm. 



Only embarrassed in paralyses of ad- 
ductors and in spasmodic affections. 



Paroxysmal, when recurrent is impli- 
cated and in spasmodic affections. 



But slightly impaired or unaffected. 



Only experienced when sensory sys- 
tem affected. Diminished sensation 
in motor paralyses and in anaesthe- 
sia. 



Increasing localized vascularity tend- '. In paralysis of abductors, occasional 
ing to lividity in any part except I vascularity of affected vocal cords, 
vocal cords or ventricles, when neo- 
plasm is whitish-grey or pale rose. 

May cause compression, narrowing and Form of glottis varying with nature 
paralysis before ulceration, which of paralysis, without extrinsic 
is always accompanied by thick- 1 thickening, 
ening. Extensive indolent, grey, 
greenish, or almost black ulcers. 

Early displacement, especially when \ Paralyzed cord not displaced, but of 



invading from pharynx, and when 
neighboring glands enlarged. 



Glandular infiltration, but complete 
immunity of other organs of body 
from similar disease both prior and 
subsequent to appearance in laryn go- 
pharynx. General emaciation. 



ten fixed in one position 



Sympathetic functional disturbances 
in other organs, or organic disease 
of cardiac or lymphatic system, or 
associated cerebral disease or 
chronic toxaemia. 



no 



DIFFERENTIAL DIAGNOSIS. 



The chronic laryngitis of syphilis cannot with certainty be distin- 
guished from the other forms of chronic laryngitis without inquiry 
into the history of the case. 

In tertiary syphilis there is deep and extensive ulceration, not neces- 
sarily preceded by thickening ; the epiglottis is attacked early, the 
ulceration is often followed by cicatrization and contraction, causing 
stenosis of the larynx. 



CROUP AND DIPHTHERIA. 

The general sign common to this class of diseases is a laryngeal 
stridor; they are divided into those where there is a formation of 
false membrane and where there is not. 
Without false membrane. 

Spasmodic croup or laryngismus stridulus. 
Inflammatory croup, simple catarrhal laryngitis. 
With false membrane. 

True croup or membranous croup. 
Diphtheria. 
The differential diagnosis between spasmodic and simple inflamma- 
tory croup is as follows: 



INFLAMMATORY CROUP. 

Onset gradual, with sore throat, 
tickling, tenderness of larynx and 
catarrh. 

Increasing difficulty in swallowing. 



Flushed face, hot, dry skin, high 
temperature (105 °), frequent pulse. 

Mucous membrane of larynx red 
and swollen, sometimes edematous. 

Remission but slight; local symp- 
toms and pyrexia continue. 

In early life a dangerous disease. 



SPASMODIC CROUP. 

Onset sudden, usually at night, 
with few or no prodromal symptoms. 



Difficulty of swallowing absent or 
temporary. 



Febrile 
marked. 



symptoms much less 
Larynx little affected. 



Intermission complete, or nearly so, 
between the croupous attacks. 

Very rarely fatal. 






DISEASES OF THE RESPIRATORY SYSTEM. 



II I 



Very considerable differences of opinion are entertained as to the 
formidable and frequent disease diphtheria. Some maintain its iden- 
tity with membranous croup, others with scarlatina, while others 
again believe it is a malady distinct in origin, course, result and treat- 
ment from them both. The last mentioned opinion is that which has 
the most adherents, and the most facts on its side. The differences 
between the diseases are fully set forth in the table subjoined : 



MEMBRANOUS CROUP. DIPHTHERIA. 

Is a local complaint. Rarely or I Is a general disease, common to all 
never occurs after puberty. ages. 



Is not contagious. Type sthenic. 



Is decidedly contagious. Type 
asthenic. 



Commences with a cough, catarrh ' Commences with a chill, sore 
and hoarseness ; little or no sore ■ throat, difficulty of swallowing ; but 
throat and difficulty of swallowing. \ neither hcarseness nor cough at the 
Cough shrill, metallic ; breathing ' outset. Stridulous breathing a late 
stridulous from the outset. symptom. 

The membranous affection begins The membranous affection begins 
in the larynx and extends to the in the throat and extends to the 



throat. 

Fauces injected but rarely swollen, 
and generally without exudation. 

Exudation never cutaneous. 

No swelling of the submaxillary 
glands 



larynx (Da Costa). 

Fauces injected, swollen and pre- 
senting exudations. 

Exudation often cutaneous. 

Submaxillary glands swollen. 



Epistaxis and albuminuria absent. Epistaxis and albuminuria frequent. 



Little and often no prostration of 
the general strength. 

Improves under emetics, local 
counter-irritants, expectorants and 
depressants. 

Is never followed by paralysis. 



Considerable, often extreme pros- 
tration. 

Demands a stimulating and sustain- 
ing treatment. 



Subsequent paralysis not infrequent. 



I I 2 DIFFERENTIAL DIAGNOSIS. 

MEMBRANOUS CROUP. DIP! 



Rarely fatal. Death from apnoea. 
Blood not changed. Spleen not 
affected. 



Frequently fatal. Death usually 
by asthenia. Blood after death 
usually fluid and dirty brown. 
Spleen enlarged and softened (J. W. 
Howard). 



TONSILLITIS. 
Inflammation of the tonsils assumes two forms, in one of which, 
the catarrhal form, the inflammation extends to the secreting tissues 
and lining membrane of the crypts, and in the other to the paren- 
chymatous structure of the gland. These two forms differ widely in 
cause, in symptoms, in treatment and result. Their diagnostic 
symptoms, as tabulated by Mr. Arthur Treherne Norton,* are 
as follows: 



CATARRHAL TONSILLITIS. PARENCHYMATOUS TONSIL- 

LITIS. 

Is a mucous inflammation of three ! Is a fibrous inflammation of from 
or four days duration. i two to four weeks duration. 

Is caused by exposure to draft, Often caused by neighboring in- 
damp, cold, etc. flammation, cutting wisdom teeth. 

Prostration and often profuse per- ! High feyer with hot dry skin, 
spiration. Pulse small and quick. Pulse strong and hard. Commonly 
Never runs on to abscess. forms an abscess. 



Both tonsils affected. 



Rarely both affected. 



Lacunae filled with masses of mor- Often covered with lymph, but no 
bid secretion resembling ulcers. j collection of secretion in lacunae. 



No edema around. 



Extensive edema. 



Treatment. — Tonics, stimulants' Treatment. — Antiphlogistics and 
and astringent gargles. I depressants, but never gargles, ex- 

1 cept in the form of warm water. 



Brit. Med. Journal, Jan., 1874. 



DISEASES OF THE RESPIRATORY SYSTEM. 



i«3 



DISEASES OF THE LUNGS. 

The study of Physical Diagnosis necessarily commences with a 
correct appreciation of the location of organs and their functions and 
sound in health ; to which must follow a clear understanding of the 
specific and peculiar alterations which each of these elements under- 
goes when it becomes a factor in disease. To acquire this, we give on 
the following pages tabular arrangements of the following subjects : 

I. The Regions of the Chest, their Contents and Normal Signs. 

II. The Normal Differences between the two Sides of the Chest. 

III. Methods of Physical Examination. IV. Normal Respiratory 
Sounds. V. Normal Voice Sounds. VI. Abnormal Resonance on 
Percussion, and its Causes. VII. Abnormal Intensity, Rhythm and 
Quality of Respiratory Sounds. VIII. Abnormal (dry) Respiratory 
Sounds. IX. Abnormal (moist) Respiratory Sounds. "X. Abnormal 
(amphoric) Respiratory Sounds. XI. Abnormal Voice Sounds. 

I. THE REGIONS OF THE CHEST. 



Region . 



i. Cervical. 



2. Supra clavicular, 



3. Clavicular. 



4. Subclavian. 



5. Mammary. 



Contents. 



Larynx and trachea. 
Apex of lung. 



Clavicles and vesicu- 
lar structure of 
lung. 



Vesicular structure of 
lung. 



Vesicular structure of 
lung. Heart on left 
side. 



Resonance on Per- 
cussion in Health. 



Clear. 



Clear. 



Cl( 



Clear on right side. 
Dull on left in 
greater part of 
region. 



Atcscultation in Health . 



Tracheal breathing and 
voice. 

Very pure vesicular 
murmur (scarcely au- 
dible); voice scarcely 
audible. 

Pure vesicular murmur 
and scarcely audible 
voice, except at the 
sternal end, where 
there are bronchial 
breathing and bron- 
chophony. 

Pure vesicular murmur 
and scarcely audible 
voice. Heart sounds 
on left side below. 

Pure vesicular murmur 
above. Heart sounds 
below on left side, 
and feeble vesicular 
murmur on right. 
Voice scarcely audi- 
ble. 



U4 



DIFFERENTIAL DIAGNOSIS. 



Region. 



6. Infra-mammary. 



7. Superior sternal. 



8. Inferior sternal. 



9. Axillary. 



10. Lateral. 



11. Supra-scapular. 



12. Scapular. 



Inter scapular. 
Infra-scapular. 



Contents. 



Anterior portion of 
base of lung. Stom 
ach below, on left 
side, liver on right. 

Division of trachea 
aorta, and great 
vessels. 

Anterior mediastinum 
above. Stomach 
below. 

Vesicular structure of 
lung. 

Vesicular structure of 
lung. 

Apex of lung. 



Vesicular structure of 
lung. 



Roots of lung and 
large bronchi. 

Base of lung. 



Resonance on Per 
cussion in Health, 



Generally tympani 
tic on left side 
dull on right. 

Clear. 



Clear above; tym- 
panitic below. 



Cl< 



Clear above; dull 
below on right 
side. 

Clear. 



Rather less clear. 

Clear. 

Clear. 



Auscultation in Health. 



Distinct vesicular mur- 
mur. Voice scarcely 
audible. 

Bronchial breathing and 
bronchophony. 

Pure vesicular murmur 
above, becoming fee- 
ble below. Voice 
scarcely audible. 

Pure vesicular murmur. 
Voice scarcely audi- 
ble. 

Pure vesicular murmur. 
Voice scarcely audi- 
ble. 

Pure vesicular murmur. 
Voice scarcely audi- 
ble. 

Pm-e vesicular murmur- 
Voice scarcely audi- 
ble. 

Bronchial breathing and 
bronchophony. 

Very pure vesicular 
murmur. Voice 

scarcely audible. 



II. NORMAL DIFFERENCES BETWEEN THE TWO 
SIDES OF THE CHEST. (A. H. Smith.) 





Right Side. 


Left Side. 


Percussion Resonance. 




A little more intense than on the 
right side. 


Vocal Resonance. 


Decidedly greater on the right 
side. 




Bronchial Whisper. 


More intense than on the left, and 
a little lower in pitch. 




Inspiratory Sound. 




A little lower on this side, more 
vesicular in quality, and slower 
in pitch. 


Expiration. 


Frequently prolonged in healthy 
individuals on this side. 





DISEASES OF THE RESPIRATORY SYSTEM. 1 1 5 

III. METHODS OF PHYSICAL EXAMINATION. 



Method of Exami- 
nation. 


Shows 


Instruments Used. 


i. Inspection. 


Form, symmetry and capacity 
of the chest. 

Local bulging, depression or 
retraction. 

Condition of intercostal spaces. 

Character and frequency of re- 
spiratory movements. 

Comparative size and degree 
of movement of the two 
sides. 

Position and extent of impulse 
of heart. 




2. Palpation. 


Comparative movement of the 




{Application of the 


two sides. 




Hand.) 


Vibration communicated to the 
chest-wall by the voice (vo- 
cal vibration or vocal frem- 
itus). 

Force of the heart's impulse. 

Occasionally certain morbid 
phenomena, as pleural and 
pericardial friction, valvular 
thrill. 




3. Mensuration — 






(a) Of Size. 


Comparative size of the two 


Graduated tape. 




sides of the chest. 


Cyrtometer. 


(6) Of Movement. 


Actual and comparative move- 


Dr. Sibson's stethometer. 




ment of the chest in respira- 


Dr. Quain's " 




tion. 


Dr. Edward's chest calipers. 
Dr. Hutchinson's spirometer. 


4. Percussion. 


Degree of resonance in various 


Plessor — A hammer tipped with india 




parts of the chest. 


rubber. 




Extent of cardiac dullness. 


The first and second fingers of 
the right hand will be found to be 
the best plessor. 
Pleximeter — A thin plate of ivory or 
bone. 

The forefinger of the left hand 
will be found to be the best plexi- 
meter. 


5. Auscultation. 


Character of respiratory mur- 


Stethoscope. — Made of wood, metal, 




mur. 


or vulcanite. 




Abnormal respiratory sounds. 


Dr. Scott Alison's bi-aural stethoscope. 




Heart sounds. 






Abnormal cardiac sounds. 




6. Succussion. 


Presence of air and fluid in 


• 




pleural cavity. 





u6 



DIFFERENTIAL DIAGNOSIS. 



Percussion may be — Immediate. — Where the chest is struck 
directly, without the interposition of any pleximeter. 

(2) Mediate. — Where an instrument termed a pleximeter is inter- 
posed between the chest and the substance with which the stroke is 
made. This may be either a thin plate of ivory or bone, or, still bet- 
ter, the first and second fingers of the left hand. 

Auscultation may be — Immediate. — Where the ear is applied 
directly to the walls of the chest. 

(2) Mediate. — Where the stethoscope is interposed between the ear 
and the walls of the chest. 

IV. NORMAL RESPIRATORY SOUNDS. 



Sound. 



Vesicular Breathing. 



Puerile Breathing. 



Bronchial Breathing. 

Tracheal ^ 

or >• Breathing. 
Laryngeal ) 



Situation where heard. 



All over the chest except the upper part of the 
sternum and the space between the scapulae, 
the inspiratory sound being louder, and three 
or four times longer, than the expiratory. 

Is the loud vesicular breathing of children, 
audible over the same parts of the chest as in 
ordinary vesicular breathing. 

Upper part of the sternum and the space be- 
tween the scapulae in many healthy persons. 

Over the trachea and larynx. 



V. NORMAL VOICE SOUNDS. 



Sound. 



Ordinary Vocal Reso- 
nance. 



Natural Bronchophony. 



Laryngophony and 
Trachophony. 



Situation and Character. 



Is the voice sound heard over the pulmonary 
regions where vesicular murmur is audible. 
A muffled, diffused sound ; the articulation of 
the voice is not appreciable. 

Heard over the upper part of the sternum, and 
between the scapulae in a certain number of 
healthy persons. A more distinct and con- 
centrated sound than the last variety. 

Voice-sounds heard over the larynx and trachea. 
Voice transmitted imperfectly articulated to 
the ear of the observer, with so much loud- 
ness and concentration as even to be painful. 



DISEASES OF THE RESPIRATORY SYSTEM. 



117 



VI. ABNORMAL RESONANCE ON PERCUSSION. 



Resonance. 



Cause. 



Diminished 

in 

various degrees, 

or altogether 

Absent. 



Increased. 



Tympanitic. 
Amphoric. 

Box-like. 

Cracked-pot 
Sound. 



'Deficiency of air in the 
lung beneath the part 
percussed, or solid or 
liquid matter between 
the walls of the chest < 
and the lung containing 
air; or extreme disten- 
sion of the chest with 
air. 



■ Air increased in quantity, 
or air in pleural cavity. 



A large cavity (or con- 
ditions resembling it) J 
with very tense walls, ' 
containing air. 



Air expelled from cavity 
by sudden pressure. 



Examples of Disease. 



Pneumonia, first stage. 
'Phthisis; contracted lung, 

with thickened pleura. 
(Edema and congestion of 

of lung. 
Tumors. 

Collapse of lung. 
Pneumonia, second and 

third stages. 
Intra-thoracic tumors and 

aneurisms. 
Effusions into pleural cavity, 

or its extreme distension 

by air. 

Emphysema. 

Tubercular cavity, having 

thin walls, and situated 

near the surface. 

Pneumothorax. 
Extreme emphysema. 

Upper part of lung com- 
pressed by fluid below. 

Pneumothorax. 
Cavities. 

Cavity of considerable size, 
with large bronchus open- 
ing into it, mouth of pa- 
tient being open. 



n8 



DIFFERENTIAL DIAGNOSIS. 



VII. ABNORMAL INTENSITY, RHYTHM AND QUALITY 
OF RESPIRATORY SOUNDS. 



Sounds. 


Chief Causes. 


Condition of 
Organs. 


Ex a?> i pies of 
Disease. 




' Feeble Breathing. 


Air entering the 


Lung partially so- 


Incipient phthsis. 






air-cells in di- 


lidified either by 


Bronchitis. 






minished quan- 


increase of solid 


Pneumonia, first 






tity and force. 


or fluid within 
it, or by pressure 
from without ; 


stage. 
Tumors. 
Pleurisy. 


>> 






dilatation of the 


Emphysema. 








air-vesicles ; in 


Pleurodynia. 


<u 






some cases lungs 




a 






not affected. 




c 


Extinct Breath i ng. 


The presence of a 


Lung solidified by 


Pleuritic effusion. 




non - conducting 


pressure upon its 


Pneumothorax. 


CO 
0) 




medium between 


surface ; plug of 


Plastic bronchitis. 






the lung and the 


mucus, fibrinous 


Tumors. 


O 




chest -wall, or 


exudation or for- 






some impedi- 


eign body in 








ment to the en- 


the bronchi, or 








trance of air into 
the bronchi. 


tumor compres- 
sing the bronchi. 






Puerile ^ 
Supple- j- Breathing. 
mentary j 


Air entering the 


Healthy. 


Disease of opposite 




air-cells with in- 
creased rapidity 
and force. 




lung or of other 
parts of the same 
lung. 








Met with as a nor- 
mal condition in 
childhood. 




Respiratory move- 


Varies with the dis- 


Pleurodynia. 


e 


'I N T E R - "] 


ments restrained 


ease causing it. 


Pleurisy. 


RUPTED 


by pain, or men- 




Debility, with pal- 


>> 


Jerking \ Breathing. 


tal emotion, or 




pitation. 




Cogged- | 


some temporary 




Hysteria. 


fi 


wheel J 


local obstruction 




Incipient phthisis. 




of the air- tubes. 




Spasmodic asthma. 


CO i 


Prolonged Expiration. 


Loss of elasticity in 


Thinning of the 


Emphysema. 


bJ3 

C3 




the lung tissue. 


walls of the air 




ctf 

o 






vesicles, with 








dilatation and 










destruction of the 




a 


. 




alveolar septa. 





DISEASES OF THE RESPIRATORY SYSTEM. 



II 9 



Sounds. 



f EXAGGER-I 

ated L Breathing. 
Coarse. J 



Breathing. 



Blowing 
Tubular or 
B r o n - 

CHIAL 

Cavernous 
[ Amphoric Breathing. 



Chief Causes. 



Increased friction 
in the air-cells 
and smaller 
bronchial tubes. 



Condition of 
Organs. 



fLung not solid- 
ified (soft 
sound). 



Friction of air in 
the bronchial 
tubes, or in cav- 
ities of the lung. 

Air passing into a 



Lung solidified 
or bronchial 
tubes obstruct - 
e d ( harsh 
sound). 
Condensation of 
the lung between 
chest wall and 
the larger bron- 
chi or cavities. 
Cavities with dense 



Exaviples of 
Diseases. 



large cavity with] wails. 
dense walls. 



Generally consist- 
ent with health 
and supplemen- 
tary. 

Heard in cases of 
uraemia and 

other blood poi- 
soned diseases, 
and in hysteria 
and nervous dis- 
eases. 

Incipient phthisis. 



Phthisis. 
Pneumonia 
Tumors. 
Tubercular 

other cavities 
Pneumothorax. 
Dilated bronchi 
Large cavities. 



and 



VIII. 


ABNORMAL DRY RESPIRATORY SOUNDS. 


Sound. 


Situation. 


Cause. 


Example of 
Diseases. 


Sibilus. 


Lesser bronchial 
tubes. 


Vibration of thick mucus attached 
to the wall of the tube, or con- 
traction of the tube, due either 
to swelling or spasm ; not easily 
removed by cough. 


Bronchitis. 

Emphysema. 

Asthma. 


Rhonchus. 


Larger bronchial 
tubes. 


Vibration of thick mucus in tubes ; 
generally easily removed by 
cough. 


Bronchitis. 



CLICKING OR CRACKLING. 



Dry Crackling. 



Humid Crackling. 



Smaller bronchi. I f Separation of the adher- 
ent walls of the bron- 
\ chi — the dry tending 
to pass into the moist 

Smaller bronchi. variety. 



Incipient phthsis. 



Phthsis, first stage. 



Pleural Friction 
Sound. 

Creaking Sound. 



Layers 

pleura. 



Movement of opposed sur- Pleurisy before effusion 
faces of pleura rough- 
ened by the deposit of 
lymph or tubercle. 



has commenced, or 
afler absorption of 
the fluid. 



120 DIFFERENTIAL DIAGNOSIS. 

IX. ABNORMAL MOIST RESPIRATORY SOUNDS. 



Sound. 


Situation. 


Cause. 


Examples of Disease. 


Crepitant Rale 


Air-vesicles. 


Opening up of collapsed 


Pneumonia in first 


{Fine or pneumo- 




air-cells, or separation 


stage. 


nic crepitation). 




of their adherent walls. 


(Edema of lungs. 
Collapse. 


SUBCREPITANT 


Smaller bronchial 


Bursting of air-bubbles in 


Capillary bronchitis. 


Rale {Medium 


tubes. 


fluid. 


Phthisical bronchitis. 


crepitation.') 






Resolution of pneu- 
monia. 
(Edema of lung. 
Pulmonary apoplexy. 


Mucous Rale 


Larger tubes and 


Bursting of air-bubbles in 


Phthisis. 


{Large crepita- 


small or moderate- 


fluid. 


Bronchitis. 


tion.) 


sized cavities. 




Haemoptysis. 


Gurgling or Ca- 


Large cavities (or 


Bursting of air-bubbles in 


Phthisis (3d stage). 


vernous RaLE. 


number of small 


fluid. 


Bronchiectasis. 




cavities). 




Abscess of lungs. 


Churning Sound. 


Lung in a state of 
disorganization. 




Gangrene of lung. 



X. ABNORMAL AMPHORIC SOUNDS. 



Sound. 


Situation. 


Cause. 


Examples of Disease. 


Splash on Succus- 


Cavity of pleura or 


Sudden disturbance of 


Pneumothorax with 


sion. 


large cavity. 


air and fluid existing 


effusion. 






together in the pleura. 


Very large cavity. 


Bell Sound. 


Cavity of pleura. 


Auscultation of an air-con- 
taining cavity, whilst 
an assistant uses two 
coins, one as a ham- 
mer, the other as a plex- 
imeter. 


Pneumothorax. 


Amphoric Echo 


Cavities. 


Vibration of air in large 


Phthisis with very 


and Metallic 




cavities with tense 


large cavities. 


Tinkling. 




walls. The former 


Pneumothorax with 






may be produced by 


effusion. 






rales and rhonchi in 








the chest, by the voice, 








and by the act of 








coughing ; the latter 








requires, in addition, a 








little fluid at the bot- 








tom of the cavity, set 








in vibration by a mo- 








mentary impulse, such 








as the fall of a drop of 








fluid, and is essentially 








the echo of a bubble. 





DISEASES OF THE RESPIRATORY SYSTEM. 



XI. ABNORMAL VOICE SOUNDS. 



Sound of Voice. 



Feeble or Absent 
Vocal Reso- 
nance. 



Exaggerated Vo 

cal Resonance. 



Bronchophony 



Pectoriloquy. 



Amphoric Reso- 
nance orEcho. 



(Egophony. 



Character of Sound. 



The obscure hum 
ming or buzzing 
noise heard over 
the normal chest 
either very feeble 
or altogether ab- 
sent. 

Voice-sounds unal- 
tered in quality or 
distribution, but 
louder and of great- 
er intensity than 
natural. 

Voice-sounds heard 
louder, clearer, and 
more vibratory than 
natural, but unat- 
tended with articu- 
lation or tactile sen- 
sation to the ear. 



Voice-sounds distinct- 
ly articulated and 
concentrated and as 
if spoken into the 
end of the stetho- 
scope. 

A ringing metallic 
sound resembling 
that produced by 
speaking into an 
empty jar. 

A tremulous vibratory 
sound resembling 
the bleating of a 
goat, or the nasal 
Punchinello voice. 



Cause. 



Primary bronchus ob- 
structed ; non-conduct- 
ing medium in pleura 
or rarefied condition of 
lung. 



Increased resounding or 
conducting power due 
to consolidation of the 
lung, or to the forma- 
tion of abnormal 
spaces. 

Much increased resound- 
ing or conducting pow- 
er. 



Large abnormal cavity 
with dense walls. 



The voice reverberating 
in a large cavity with a 
small aperture. 



A thin layer of fluid in the 
pleural cavity, with con- 
densed lung behind. 



Examples of Disease. 



Tumors compressing 
or foreign body in 
bronchus. 

Pneumothorax. 

Hydrothorax. 

Pleuritic effusion. 

Emphysema. 

Incipient phthisis. 
Dilatation of bronchi. 



Cavities' due to phthi- 
sis or dilatation of 
the bronchi. 

Consolidation of the 
lung resulting from 
collapse, hsemor- 
rhagic infarctions, 
pneumonia, phthi- 
sis, cancer, etc. 

Phthisis, dilated bron- 
chi, etc. 



Phthisis. 
Pneumothorax. 



Pleurisy with effusion. 



122 DIFFERENTIAL DIAGNOSIS. 

The late Dr. John Hughes Bennett laid down the following 
practical 

GENERAL RULES FOR THE DIAGNOSIS OF DISEASES 
OF THE RESPIRATORY SYSTEM. 

1. A friction murmur heard over the pulmonary organs indicates 
a pleuritic exudation. 

2. Moist or dry rales, without dulness on percussion, or increased 
vocal resonance, indicate bronchitis. 

3. Dry rales accompanying prolonged respiration, with unusual res- 
onance on percussion, indicate emphysema. 

4. A moist rale at the base of the lung, with dryness on percussion, 
and increased vocal resonance, indicates pneumonia. 

5. Harshness of the respiratory murmur, prolonged respiration and 
increased vocal resonance confined to the apex of the lung, indicate 
incipient phthisis. 

6. Moist rales, with dulness on percussion, and increased vocal 
resonance at the apex of the lung, indicate either advanced phthisis 
or pneumonia, generally phthisis. 

7. Circumscribed bronchophony or pectoriloquy, with caverncfus dry 
or moist rale, indicates a cavity. This may be dependent on tuber- 
cular ulceration, a gangrenous abscess, or a bronchial dilatation. The 
first is generally at the apex, and the two last about the centre of the 
lung. 

8. Total absence of respiration indicates a collection of fluid or of 
air in the pleural cavity. In the former case there is diffused dulness, 
and in the latter diffused resonance on percussion. 

9. Marked permanent dulness, with increased vocal resonance and 
diminution or absence of respiration, may depend on a chronic pleu- 
risy, on thoracic aneurism, or a cancerous tumor of the lung. 



DISEASES OF THE RESPIRATORY SYSTEM. 1 23 

THE FORMS OF PHTHISIS. 

The most recent writers, both in the United States and Europe, are 
agreed in recognizing three forms or varieties of phthisis.* It is ot 
import, both to the prognosis and therapeutics of the case, to distin- 
guish these aspects of the disease ; and although in many cases the 
type is by no means prominently defined, in the majority there is no 
great difficulty in assigning them to one or another class. The three 
forms are : 

1. Catarrhal or Inflammatory Phthisis: " Desquamative pneumonic 
phthisis." (Buhl.) 

2. Fibroid phthisis. Cirrhosis of the lung. Chronic pneumonic 
phthisis. Bronchial phthisis. Laryngeal phthisis. 

3. True tuberculosis, including acute miliary tuberculosis. 

On the clinical recognition of these three varieties, Dr. Alfred L. 
Loomis says : 

If a case of phthisis presents himself for examination, and it is 
found that the disease began with the ordinary symptoms of a cold 
and that this cold periodically improved and relapsed, but that the 
cough never left him, but became more pronounced, and deepened 
into what we usually find in advanced phthisis, accompanied with 
emaciation and occasional haemoptysis, we are in a position to say that 
the patient presents the usual characteristics of catarrhal phthisis. 

If, however, he gives a history of persistent cough for many years 
as is found in chronic bronchitis, and eventually furnishes the rational 
history of advanced phthisis, with the presence of cavities on the lung, 
we may consider him as having the disease of the fibrous form, in 
which cavities are the result of dilated bronchi. 

Finally, if the patient says that an early sympton was emaciation, 
with impaired digestion, accompanied by a dry, hacking cough, and 
if, moreover, there was a steady rise in the temperature, we are justi- 
fied in suspecting the presence of tubercular phthisis. 

*Dr. A. B. Shepherd, Med. Press and Circular, July, 1876; A. L. Loomis, N. Y. 
Med. Journal, Feb., 1877; Roswell Park, Chicago, Med. Journal, Sept., 1878, etc, 



124 



DIFFERENTIAL DIAGNOSIS. 



Period of Invasion. 



COMPARISON OF THE FORMS OF PHTHISIS, 

Catarrhal. 
Precursory catarrh, sometimes pneumonia, 
croup, measles, or other inflammatory disease ; 
cough " deepens," proceeding from the trachea 
to the alveoli and bronchioles, indicated by 
dark yellow streaks in the sputum. Fever and 
wasting not marked at outset. Haemoptysis 
not common at this period. 



Temperature. 



Physical Signs. 



The hectic is more of a remittent or inter- 
mittent than of a continued type ; with a range 
of, say, i.i° C. between evening and morning 
temperature ; the evening elevation being a con- 
stant feature. 

The fever may present all possible variations 
in the same individual. A sudden accession 
may be regarded as an indication of some fresh 
inflammatory process ; e.g., pleuritis, pneumonia. 

With marked evening rise of temperature, the 
rate of respiration does not correspondingly 
accelerate ; hardly ever more than six or eight 
breaths per minute. 

I 

In the first stage, feeble, harsh or puerile 
respiratory sounds are heard, with all the signs 
of catarrh at apices. 

Dullness usually marked ; when its area accords 
with the other signs it is a comparatively favor- 
able feature. 

The presence of lobular infiltration may, in 
some cases, cause a hollow or tympanitic note. 

"Cracked-pot" resonance over a cavity with 
thin walls. 

Fremitus is intensified over cavities connect- 
ing with bronchi and containing air. 

Bronchial respiration, bronchophony, and 
sonorous rales are heard after extensive indura- 
tion. 



DISEASES OF THE RESPIRATORY SYSTEM. 



25 



COMPARISON OF THE 

Fibroid. 
More or less dyspnoea, gradually in- 
creasing. Cough, worse in winter, 
sometimes absent in summer. Hae- 
moptysis not infrequent. Pulse slightly 
rapid, perhaps irregular. Expectora- 
tion often profuse, mucous or muco- 
purulent. 



Elevation of temperature and other 
febrile symptoms very variable, some- 
times wholly absent (Bristowe). No 
special type. 



Notable dullness on percussion, the 
diminished resonance being sometimes 
tympanitic. Respiration bronchial, 
or broncho-vesicular. Bronchophony 
and increased vocal resonance. The 
affected side becomes contracted either 
entirely or in part. 



FORMS OF PHTHISIS. 

Tubercular. 
Commences in the alveoli, bron- 
chioles, or connective tissue. Pallor, 
fever, emaciation and night-sweats 
early. Cough hoarse and hard, voice 
hoarse or inaudible, distressing laryn- 
gitis. The sputa retain the crude char- 
acter of the mucous sputa of acute 
bronchitis. Spleen somewhat enlarged. 

The hectic is of a continued type ; 
temperature always above normal, but 
not much higher in the evening than 
in the morning ; i. e., the remissions 
not well marked ; moreover, it resists 
treatment. 



Signs not well marked, not suffici- 
ently so to account for the symptoms. 
Solidification not extensive. Expan- 
sion unequal. 



126 DIFFERENTIAL DIAGNOSIS. 

THE DIAGNOSIS OF INCIPIENT PHTHISIS. 
There is no absolutely sure symptom of phthisis previous to per- 
cussion dullness, but a very strong presumption of its approach can 
be drawn from the presence of the following changes: 

1. Emaciation, Where there is progressive emaciation without 
assignable cause, and especially if the appetite continues good, phthi- 
sis should always be suspected. The loss of flesh first shows itself in 
a retraction of the skin over the cheeks, a thinning of the lips and ears, 
and a pinched appearance of the nose. The nostril on the affected 
side is usually slightly more dilated than the other. 

2. Ancemia, seen in the bluish hue of the sclerotic, and in the pallor 
of the cheeks. 

3. Sore throat and hoarseness. A very early symptom. On exam- 
ination the pillars of the fauces are found hyperaemic, the throat con- 
gested and the bronchial glands enlarged. 

4. Depression of the acromial end of the clavicle, on the affected side. 
In health the acromial end is slightly higher than the sternal end. 

5. Rheumatoid pains in the arms coming suddenly at night or in 
the early morning not increased on moving the arms. 

6. Pityriasis versicolor, in the form of pale yellow or reddish spots 
appearing on the skin of the chest, neck and arms. This is considered 
by Aufrecht a very characteristic symptom. 

7. In regard to the breathing, what is considered as suspicious are 
weak, jerking, " cogged wheel" or sonorous sounds, rough breathing, 
a lengthened strong expiration after soft inspiration, especially when 
in circumscribed regions these sounds differ from those on the other 
side of the chest. The most appropriate spot to note the duration of 
expiration is over the larynx or trachea ; and in proportion as the 
tubercular deposit is more extended, the expiratory murmur becomes 
more tubercular in quality and higher in pitch. (Armor.) In normal 
cases the respiratory sound becomes weaker in the supra-spinous 
region outward from the vertical column. Dr. Heitler considers it 
therefore strong evidence of incipient pulmonary phthisis if the respi- 
ratory sounds during expiration are more sonorous over these regions 
than nearer to the vertebral column * 

* Dobell's Reports on Diseases of the Chest. 1877. 



DISEASES OF THE RESPIRATORY SYSTEM. \2J 

8. Unequal expansion of chest is an early sign of commencing dis- 
ease of the apex. The expansion is less on the diseased side. 

9. Alterations in temperature curve frequently take place early. The 
temperature may be low, but its characteristic range will be: (1) a 
marked rise after 2 P. M. ; (2) a rapid fall after 10 P. M. ; (3) min- 
imum about 7 A. M. ; (4) recovery to normal about 10 A. M. (C. T. 
Williams.) Such a curve must always excite grave suspicions. 

10. Rapidity of pulse. A persistent and sustained increase in the 
pulse rate, without cardiac disease, is a valuable rational sign, present 
very early in most cases. 

11. The cougli of incipient phthisis is usually short, hacking, and 
dry, or with a slight, glairy, mucous expectoration only. From the 
presence of fragments of the pulmonary fibrous tissue in the sputum, 
"we are sometimes enabled to suspect the existence of consumption 
before the physical signs of even its early stages are well defined." 
(Da Costa.) 

12. Hcemoptysis. The appearance of haemoptysis is always a seri- 
ous element of diagnosis. Light, frothy, red blood, rising without 
apparent exertion, is an indication which, in America at least, has 
proved of graver meaning the more it has been investigated.* On the 
other hand, there may be considerable haemoptysis, with marked dull- 
ness at the apex, without the significance of tubercle. f 

13. Clubbing of the finger ends, when associated with incurvation ot 
the sides and tips of the nails, means obstruction of the subclavian 
veins, which is one of the earliest effects of tuberculosis; but clubbing 
without this incurvation is rather against the probability of tubercle 
(Dobell). 

1.4. Amennorrhea is, in young females, often one of the earliest 
signs of phthisis. 

15. A red line is occasionally noticed on the gums at the base of 
the teeth. 

16. Arthritis. M. LaveranJ has drawn attention to the occurrence 
of arthritis as the first symptom of a general tuberculosis. 

* See second Report of the New York Mutual Life Insurance Company, 187 J. 
f See Dr. J. M. Da Costa, in Medical and Surgical Reporter, July 13, 1878. 
% Le Progres Medical, Oct. 25, 1876. Quoted by Dr. M. Anderson. 



128 



DIFFERENTIAL DIAGNOSIS. 



To examine sputa for elastic fibres, mix it with a soda solution 



5- 



Liquor sodae, 
Aquas destill., 



i part 
2 parts. 



M. 



And boil for four or five minutes. Then dilute with an equal 
quantity of distilled water, and pour into a flat porcelain vessel. The 
particles suspended in the water may then be taken out and examined 
under the microscope. The fibres in this process are brown, slightly 
reticulated, and a fraction of a millimetre in length. (Sokolowski.) 
DIAGNOSIS BETWEEN INCIPIENT PHTHISIS AND 
BRONCHITIS. 



INCIPIENT PHTHISIS. 
i. The cough commences gradu- 
ally, without marked disturbance 
or coryza, often preceded by slight 
loss of flesh and strength. 

2. The cough is generally dry and 
hacking at commencement, followed 
by the expectoration of a thin mu- 
cous fluid, which soon becomes thick 
and opaque, or is slightly streaked 
with blood. 

3. Examination by the microscope 
shows portions of lung tissue (yellow 
elastic fibres) in the sputa 

4. Pain of a wandering character 
about the chest, especially under the 
clavicles or between the shoulders. 

5. Evening rise of temperature. 



6. The morbid physical signs usu- 
ally confined to upper lobe of one 
side ; are very persistent, and if on 
both sides at first, apt to subside on 
one and increase on the other. 

7. Family history and general ap- 
pearance indicate tuberculous ca- 
chexia. Most frequent in youth. 



BRONCHITIS. 
1 . The cough commences suddenly, 
and is usually ushered in by feverish- 
ness and coryza. 



2. The cough is accompanied with 
expectoration almost from the first; 
generally abundant ; frothy or muco- 
purulent ; not often blood-stained. 



3. No evidence of destruction of 
lung tissue. 



4. A feeling of tightness and raw- 
ness behind the sternum, aggravated 
by coughing. 

5. Elevation of temperature not 
particularly marked toward evening. 

6. Morbid signs usually predomi- 
nate in the lower lobes ; are on both 
sides ; are of temporary duration, and 
subside gradually and equally on both 
sides. 

7. No marked hereditary tendency; 
common at all ages. 



DISEASES OF THE RESPIRATORY SYSTEM. 



I2 9 



The general clinical history of phthisis may be summed up in the 

following brief table : 

' PHTHISIS. 



Stage of the Disease. \ 



Symptoms. 



st stage 



(incipient) 



2(1 stage 



Cough at first dry, then 
with expectoration of mu- 
cus, frequently streaked 
or dotted with blood, or 
with copious haemoptysis. 
Dyspnoea. Pains in vari- 
ous parts of the chest, es- 
pecially on the affected 
side. Dislike to fatty 
articles, and other dyspep- 
tic symptoms; tendency 
to vomiting after parox- 
ysms of coughing. Night- 
sweats. Emaciation. In 
females, disturbance of the 
catamenial functions. Oc- 
casionally hectic. 



Physical Signs. 



Diminished movements. 
Increased vocal fremitus. 
Loss of resonance, rise in 
pitch, or a boxy, wooden 
note beneath the clavicle 
or in the interscapular 
region. Feeble, coarse, or 
interrupted vesicular mur- 
mur, with prolonged expi- 
ration. Increased vocal 
resonance. Occasional si- 
bilus or creaking friction 
sound. Heart sounds ab- 
normally loud over af- 
fected side. Subclavian 
murmur. Puerile respira- 
tion on sound side. 



(confirmed). 



Cough more severe, with Greater diminution of 



3 d sta g e 



puriform expectoration, ofj 
a yellow or greenish hue, J 
and often bloody. Profuse 
night-sweats and rapidly 
progressive emaciation. 
Pinched and anxious ex- 
pression. Loss of appetite. 
Thirst. Diarrhoea. Some- 
times hectic. 



Cough rather looser, still 
(advanced). [ with puriform ( nummular 1 
I expectoration, or attacks 
of copious haemoptysis. 
Extreme emaciation and 
debility, with or without 
night-sweats. Voice husky 
and hollow. Aphthae on 
mouth and fauces. Hectic. 
Clubbed nails. 



movement of the affected 
side, and some amount of 
flattening. Increased vocal 
fremitus. Increased dull- 
ness, extending down- 
wards. Bronchial breath- 
ing, mixed with mucous 
rales or with click at the 
end of each inspiration. 
Bronchophony. 

Scarcely any movement of 
the affected side. Marked 
flattening. Increased 

vocal fremitus. Dullness 
less marked. Box-like re- 
sonance of cracked-pot 
sound. Cavernous breath- 
ing, with gurgling and 
splash on cough. Occa- 
sionally metallic sounds. 
Pectoriloquy. 



^3° DIFFERENTIAL DIAGNOSIS. 

PHTHISIS. 



Complications 

not restricted to 
any particular 

stage of phthisis. 



The chief of these are : Affections of the larynx and 
trachea, especially ulceration ; bronchitis, pneumonia, 
or pleurisy ; perforation of the pleura, with pneumo- 
thorax; enlargement of the external absorbent 
glands, or of those in the chest and abdomen; tuber- 
cular peritonitis; ulceration of the intestines, espe- 
cially the ileum; fatty or amyloid liver; fistula m 
ano ; various forms of Plight's disease ; diabetes ; 
pyelitis; tubercular meningitis, or tubercle in the 
brain, and thrombosis of the veins of the legs. 

POST MORTEM APPEARANCES. 

First stage. Usually most marked at, or even confined to, one 
apex, where are to be seen gray, semi-transparent nodules, varying 
in size from a small pin's head to a hemp-seed; the lung-tissue around 
these nodules may be healthy, but is generally hyperaemic and con- 
gested, slightly increased in density. In more 'advanced cases, in ad- 
dition to the miliary nodules, there may be small yellow masses, less 
defined, but larger than the gray variety. Both kinds may either be 
scattered or several in one group, forming a considerable mass. 

Second stage. Commencement of caseation and softening in the 
consolidated portion, inflammation of the surrounding parenchyma, 
together with obliteration of the blood-vesssels and formation of 
cicatricial tissue. 

Third stage. Cavities of various sizes and forms, and either single 
or numerous, generally containing puriform fluid. Ulceration and 
dilation of the bronchial tubes. Lung indurated and puckered in 
proportion to chronicity of disease. 

ACUTE PHTHISIS, ACUTE MILIARY TUBERCULOSIS, 
GALLOPING CONSUMPTION, TYPHOID PHTHISIS. 

The formidable disease known under these names is probably, as 
M. Bouchut remarks, more common than is generally supposed, as 
it is generally mistaken either for capillary bronchitis or typhoid 
fever, especially the latter. Its duration is brief, sometimes less than 
a fortnight (Da Costa), and its termination almost invariably fatal. 



DISEASES OF THE RESPIRATORY SYSTEM. 1 3 I 

Its onset is marked by chills and feverishness, nausea, vomiting 
and diarrhea. There is a rapid pulse; dyspnea; pain in the chest ; 
cough, usually with profuse expectoration. Great exhaustion, pro- 
fuse sweats, rapid emaciation, and delirium, soon follow. One or 
both lungs exhibit unusual dullness, while the auscultatory sounds 
differ greatly in different cases. 

The following are the marked diagnostic features of the disease : 

1. Facial expression. The countenance is livid, indicating plainly 
an impediment to the passage of blood through the lungs. In 
severe typhoid fever the cheeks are slightly flushed, the facial mus- 
cles tremulous, the eyes dull, and the mouth partly opened, present- 
ing an appearance characteristic of the disease.* 

2. The delirium of acute phthisis is restless and often violent, but 
the rambling and wild talk is connected usually with things present 
or near. In typhoid fever the delirium is generally muttering and 
low; the mind deals with things absent, and the patient "is like a man 
talking in his dreams." (Watson.) 

3. The tongue in acute phthisis, at first covered with a white fur, 
soon becomes red, glassy and dry. In typhoid it usually changes to 
a brownish hue. 

4. The ophthalmoscope is a most positive aid to the diagnosis, ac- 
cording to M. Bouchut. In all cases of acute, general, miliary tuber- 
culosis, an ophthalmoscopic examination will reveal the presence of 
tubercular granulations in the choroid,f thus placing the nature of the 
disease beyond doubt. 

4. Abdominal symptoms. Diarrhoea and gastric and abdominal pains 
are often present in acute phthisis; but the red spots of typhoid are 
not seen. 

5. Chest symptoms. Dyspnea is present always, but the orthopnea 
of capilliary bronchitis is rare (Shaw). The respiration is greatly 
quickened, and the proportion to the pulse averages I : 3 (Walshe). 
The presence of percussion dullness, a sinking in at the upper part of 
the chest, and the occurrence of hemorrhage, are conclusive evidence 
of tubercle (Da Costa). 

* L. J. Woollen, American Praclilioner, July , 1871. 
•j- Medical Times and Gazelle. January, 1875. 



132 



DIFFERENTIAL DIAGNOSIS. 



DIAGNOSIS OF SYPHILITIC PHTIHSIS. 
The distinctive traits of this form of consumption have lately been 
separately studied by Dr. MacSwiney, of Dublin, and Dr. Pentimalli, 
of Naples. Their results are combined in the following schema: 

1. Absence of hereditary tendency, of a phthisical habitus, and of 
preceding pulmonary affections. 

2. History of syphilitic disease in other organs, and presence of the 
syphilitic cachexia in its tertiary stage. 

3. The disease never begins in the apex, and is limited in its seat, 
being unilateral and generally posterior (Pentimalli). 

4. Haemoptysis rare, febrile symptoms absent or slight. 

5. Slowness in development, the acuter phthisical symptoms not 
manifest. 

6. Exacerbation of pain during the night. 

7. A peculiarly fetid breath. 

8. Reference of the feeling of oppression to the larynx rather than 
to the chest. 

9. Failure of ordinary measures, and improvement under specific 
medication. 

BRONCHITIS, ACUTE AND CHRONIC. 
In most cases of bronchitis the inflammation is seated in the larger 
bronchial tubes. There is more or less swelling of their lining mu- 
cous membrane, not generally sufficient to prevent a free passage to 
the breathing air. The character of its acute and chronic form are as 

follows : 

ACUTE BRONCHITIS. 



1st or Dry 
Stage. 



Symptoms. 



Physical Signs. 



Chilliness, followed by fre- Breathing hurried. Rhonchal 



quent pulse and febrile 
symptoms ; pains in limbs. 
Substernal pain. Hoarse 
dry cough. Feeling of 
oppression and tightness 
about the chest. 



fremitus may be felt. Reso- 
nance on percussion unim- 
paired. Feeble vesicular 
murmur, mixed with rhon- 
chus and sibilus. Puerile 
breathing in unobstructed 
parts of lung. Vocal reso- 
nance not materially altered. 



DISEASES OF THE RESPIRATORY SYSTEM. 



133 



2d or Moist 
Stage. 



3d Stage. 
(Termina- 
tion favor- 
able.) 



(Unfavora 
ble.) 



Symptoms. 



Physical Signs. 



Cough, with expectoration of 
frothy, transparent mucus,! 
mixed with air-bubbles of 
various sizes, and occasion-! 
ally tinged or streaked with! 
blood. Urgent dyspnoea, 
often amounting to ortho- 
pncea. Lividity and fe- 
brile symptoms increased. 
Restlessness at ni^ht. 



Breathing hurried. Rhonchal 
fremitus may be felt. Reso- 
nance on percussion clear or 
only very slightly impaired. 
Feeble vesicular murmur mix- 
ed with rhonchus, sibilus and 
mucous rales. Vocal reso- 
nance unaltered. 



Gradual remission of the Less amount of sonoro-sibilant 
symptoms. Expectoration | and mucous rales, with return 

of normal vesicular breath- 
ing. 



becomes thick, greenish, 
and opaque, and some 
times nummulated. 



Dyspnoea very urgent, signs In addition to the sign-, of the 



of impending suffocation. 
Profuse cold sweats. Sink- 
ing, drowsiness and delir- 
ium. Less cough, absence 
of expectoration. 



second stage, tracheal rales 
may be heard. 



The post mortem appearances are: Congestion of mucous mem- 
brane of bronchial tubes, with some degree of swelling and dryness 
of surface. 

Lungs do not collapse when the chest is opened. The mucous 
membrane of the bronchi is red and swollen, and the tubes filled 
with frothy, adhesive mucus. •■ 

CHRONIC BRONCHITIS. 

Symptoms. Physical Signs. 



Two chief forms, the one char- 
acterized by the sputa being expec- 
torated with great difficulty, con- 
sisting of small, grey, semi-trans- 
parent pellets, and tending towards 
emphysema ; in the other the sputa 
are abundant, muco-purulent, and 
brought up with ease ; dilatation 
of the bronchi frequently associ- 



Respiration labored and abdom- 
inal. Vocal fremitus not materi- 
ally altered ; rhonchal fremitus can 
generally be felt. Impairment or 
resonance or a hyper-resonant note, 
according as collapse of lung and 
consolidation or emphysema pre- 
dominate, the former most marked 
at the bases, the latter at the an- 



134 DIFFERENTIAL DIAGNOSIS. 



terior part. Feeble vesicular mur- 
mur. Rhonchus, silibus, and mu- 
cous rales. Vocal resonance varies. 



ated with this form. The cough 
generally comes on at the approach 
of winter; with the history of 
former attacks. Dyspnoea ; lividity 
of surface ; and in some cases the 
symptoms resemble those of 
chronic phthisis, as wasting, with 
night sweats and hectic. 

The post mortem appearances are : 

Lungs generally much congested, presenting a dark livid hue, with 
portions collapsed, and others emphysematous. Bronchial tubes fre- 
quently dilated. Mucous membrane thickened, uneven, sometimes 
ulcerated, covered by a thick, puriform secretion, or sparingly coated 
by a tenacious, glairy, semi-transparent substance. 

The principal diseases with which bronchitis may be confounded 
are pneumonia, pleurisy and phthisis. But each of these is charac- 
terized by the presence of definite physical signs, which are not to be 
found in ordinary bronchitis. For instance, in this disease there is no 
disparity between the two sides of the chest in the resonance obtained 
by percussion, nor in vocal resonance, the bronchial whisper and 
fremitus. The swelling of the bronchial mucous membrane may 
cause some dimunition of the intensity of the vesicular murmur; but 
as the affection is bilateral and the bronchial tubes on both sides are 
affected equally, both in degree and extent, there is no appreciable dis- 
parity between the two sides. Sometimes temporary weakening or 
suppression of the murmur may be caused by a plug of mucus, 
which will be detected on a second examination (Flint). 

CAPILLARY BRONCHITIS. 

Acute capillary bronchitis may, however, be taken for some of the 
forms of pneumonia, and in fact the descriptions of some writers 
would lead to the belief that they have committed this error. The 
following distinctions will make the diagnosis easy in most cases : 



DISEASES OF THE RESPIRATORY SYSTEM. 



35 



CAPILLARY BRONCHITIS. 

Commences in the external air pas- 
sages as a common cold and extends 
downward. 

Always bilateral. 



PNEUMONIA. 
Commences suddenly with a chill, 
and attacks the lungs directly. 

Generally unilateral. 

Dullness on percussion more or less 



Normal or exaggerated resonance 
on percussion unless collapse has com- extensive at the outset 
menced. 



Sub-crepitant rales on both sides of 
the chest. 

Respiration not bronchial, 50 or 
more; pulse 150 or more. 

Muco-purulent expectoration ; no 
plastic lymph. 

Dyspnoea intense ; cyanosis early. 
No pain or but little. 

Death from asphyxia; mortality 
more than half. 



Crepitant rale. 



Respiration bronchial, 25 to 40 
per minute. Pulse 100 to 130. 

Rust-colored expectoration ; plas- 
tic lymph. 

Dyspnoea less ; cyanosis late if at all. 
Pain in the side. 

Death from asthenia ; mortality ten 
I per cent. 



PNEUMONIA AND PLEURISY. 

Ordinary acute inflammation of the lungs in its early or first stage 
is well marked by the presence of a moderate or slight dullness on 
percussion over the affected lobe, and the detection on auscultation of 
the crepitant rale. The latter is indeed not invariably present, but when 
it is, taken in connection with the symptoms, it is pathognomonic. 

When the inflammation is of the pleural surfaces of the lungs — in 
other words, acute pleurisy — the marked characters are a sharp pain 
in the side, and consequent feeble respiratory murmur from restrained 
respiration, and a rubbing friction sound. 

Later in the diseases the rust-colored expectoration of pneumonia 
on the one hand, and the physical signs of effused liquid into the 
pleural cavity in pleurisy on the other hand, offer distinctive features. 

The general clinical histories- of the diseases are given in the fol- 
lowing tables : 



136 



DIFFERENTIAL DIAGNOSIS. 

PNEUMONIA. 



1st Stage. 
(Engorgement.) 



2d Stage. 

(Red hepatiza- 
tion.) 



3d Stage. 

(Gray hepatiza- 
tion). 



Symptoms. 



Single, severe rigor (or convul- 
sions in children*, followed by 
heat of skin. Increased fre- 
quency of pulse. Respiration 
greatly accelerated, with conse- 
quent disturbance of the pulse- 
respiration ratio. Dyspnoea. Pain 
in the side, increased by cough 
or deep inspiration. Cough, at 
first dry, with rusty sputa about 
the second or third clay. Ina- 
bility to lie on affected side. Di- 
lating alse nasi. Herpes about 
lips. Frontal headache. 

Increased distress and dyspnoea. 
Respiration and speech panting. 
Cough more urgent, and sputa 
still rust-colored, extremely vis- 
cid, and tenacious. Absence or 
deficiency of chlorides in the 
urine. 



Aspect much distressed. Face pale 
and livid. Great failure of vital 
powers. Hectic and delirium. 
Cough continues, and the sputa 
are either absent, or sometimes 
they remain rust-colored ; at oth- 
ers become purulent or dark, like 
prune-juice, thin and fetid. 



Physical Signs, 



Diminished movement on 
the affected side. Res- 
piration abdominal. Vo- 
cal fremitus normal. Per- 
cussion note not materi- 
ally affected. Feeble 
vesicularbreathing. Fine 
crepitant rale, most fre- 
quently heard at base of 
lung and at the end of 
inspiration. 



Very slight movement. 
Vocal vibrations well 
marked. Dullness on per- 
cussion. Tubular breath- 
ing and bronchophony, 
generally accompanied 
by some rales, if at the 
commencement of the 
2d stage of a crepitant 
character, and afterwards 
of a mucous nature. 

Absolute dullness on per- 
cussion. Tubular breath- 
ing and bronchophony, 
frequently with gurgling 
rales where the lung is 
disorganized. 



Post-mortem Appearances. — Lungs: 1st stage. Engorged with 
frothy and bloody serum. Dark-red color externally, and on section. 
Crepitating less and heavier than sound lung, but still floating in 
water. Pulmonary tissue slightly softened. 

2d. Red externally, red or mottled and granular on cut surface, and 
of liver-like solidity. Easily torn, and' with fluid exuding on pressure 



DISEASES OF THE RESPIRATORY SYSTEM. 



37 



less abundant than in first stage, but thicker, and towards the end of 
this stage becoming purulent. Not crepitating, and sinking in water. 
3d. Reddish yellow or gray. More rotten and friable. Purulent 
fluid exudes from the cut surface ; and, on pressure, the whole lung 
may be reduced to a pulp-like mass. 

PLEURISY. 



Pleurisy : 
1st Stage, or 
Stage of Hy- 
peremia. 



r 



1 Stage, 
Stage of Ef- 
usion. 



Empyema. J 



Symptoms . 



Rigors, or more frequently 
more chilliness. Sharp, 
stabbing pain in the side, 
increased by deep inspira-l 
tion or cough, accompa -j 
nied generally with some! 
tenderness on pressure.! 
Breathing short and hur- 
ried. Respiration chiefly! 
abdominal, with inability 
to lie on the affected side. 
Short, dry cough. Pulse 
full and bounding. Feb- 
rile symptoms. 

Cough, dyspnoea, sense of 
weight and fulness of the 
affectedside. Febrile symp- 
toms less marked. Patient 
lies toward, not on, the af- 
fected side. Complexion 
inclined to be dusky. 



More decided febrile dis- 
turbance of a hectic type, 
night sweats. Morning 
remissions and evening ex- 
acerbations. Face puffy 
and semi - transparent. 
Clubbing of the finger- 
ends. If pointing in- 
wardly abundant purulent 
sputa. 



Physical signs. 



Diminished movement on the af- 
fected side. Friction fremitus 
may sometimes be felt. Percus- 
sion sound not materially altered. 
Vesicular murmur feeble and 
jerking in rhythm. To-and-fro 
friction sound. 



Almost total absence of movement 
of the affected side, which is un- 
duly prominent, the intercostal 
spaces being obliterated or even 
bulging. Integuments occasion- 
ally cedematous. Vocal vibra- 
tions absent. Complete dullness 
on percussion, most marked in 
the dependent portions of the 
chest, and sometimes altered by 
change of posture. Heart pushed 
over to sound side, and dia- 
phragm pushed down, so that the 
liver and stomach descend lower 
into the abdomen than in health. 
Vesicular murmur almost, or 
quite, absent. Frequently bron- 
chial breathing along the spine. 
Puerile preathing in sound lung. 
Voice sounds absent or feeble, 
except when the layer of fluid is 
thin, and then there may be 
cegophony. 



3» 



DIFFERENTIAL DIAGNOSIS. 



3d Stage (Res- 
olution after 
Effusion). 



Symptoms. 



Gradual diminution of the 
cough, dyspnoea, and other 
symptoms. Returning abil- 
ity of the patient to lie on 
the sound side. Gradual 
return of displaced organs 
to their normal position. 



Physical signs. 



The movement of the chest grad- 
ually increases. Return of vocal 
vibration and friction fremitus. 
The dullness on percussion dimi- 
nishes from above downwards, 
but the resonance generally re- 
mains box-like for a considerable 
period. Gradual restoration of 
the vesicular murmur, at first 
weak and distant, then somewhat 
harsh, and subsequently of a 
normal character. Reappearance 
of the friction sound for a time. 
Pseudo rales occasionally to be 
heard. GEgophony sometimes to 
be heard, more often broncho- 
phony, and ultimately normal 
vocal resonance. 



Post-mortem Appearances. — 1st. stage. Pleura opaque and drier 
than natural, roughened and highly vascular, and presenting a close 
net-work of blood-vessels with ecchymoses. 

2d. Fluid, either serous or purulent, mixed with shreds of creamy 
lymph, in the cavity of the pleura. Lungs pushed upwards and back- 
wards towards the spine, its surface coated with a layer of lymph of 
the same kind as that mixed with the fluid. The lung collapsed and 
carnified. 

3d. If the effusion has been of long duration the lung remains carn- 
ified and bound down by adhesions, and the chest-wall undergoes 
retraction or depression, the ribs overlap, and there is more or less 
lateral curvature of the dorsal spine towards the diseased, and of the 
lumbar towards the healthy side. 



DISEASES OF THE RESPIRATORY SYSTEM. 



139 



DIAGNOSIS BETWEEN PLEURISY WITH EFFUSION 
AND PNEUMONIC CONSOLIDATION. 



PLEURISY. 

1 . Begins with chilliness or several 
slight rigors. 

2. Sharp, catching, stitch-like pain 
in the side. 

3. Cough, dry or with little mucous 
expectoration, very painful, and re- 
pressed by the patient. 

4. Pyrexia is not great and the skin 
may be moist. 

5. Excretion of chlorides not af- 
fected. 

6. Pulse-respiration ratio not af- 
fected. 

7. Affected side rounded ; dis- 
placement of heart. 



8. Feeble or absent vocal fremitus. 



9. Absolute dullness on percussion, 
transgressing the median line in front. 

10. Feeble or absent vesicular 
breathing • bronchial breathing at the 
root of the lung. 

1 1 . Vocal resonance absent, some- 
time* oegophonic. 



PNEUMONIA. 

1. Begins with a severe and pro- 
tracted rigor. 

2. Pain does not catch the breath ; 
is more of a dull character. 

3. Cough frequent and severe, with 
rusty, viscid expectoration. 



4. Great febrile disturbance, skin- 
hot and pungent. 

5. Diminution of absence of chlor- 
ides in the urine. 

6. Pulse-respiration ratio may fall 
to 2 : 1. 

7. No alteration in the shape of the 
chart or of the intercostal spaces ; 
heart not displaced. 

8. Vocal fremitus usually much in- 
tensified. 

9. Less intense dullness, not trans- 
gressing the median line. 

10. Marked tubular breathing, 
often of a metallic character. 



11. Loud broncophony. 



4 o 



DIFFERENTIAL DIAGNOSIS. 



DIAGNOSIS BETWEEN PNEUMONIA AND PULMONARY 

APOPLEXY. 



PULMONARY APOPLEXY. 

Nearly always associated with heart 
disease or pyaemia. 



PNEUMONIA. 

Generally an independent disease. 



Outset sudden. Fever absent ex- | Onset with malaise and chill. Fe- 
cept in pyaemia. Pulse irregular and ■, ver. Pulse rapid, 
intermittent. 

Expectoration blackish, with small | Expectoration rust-colored ; no 



dark clots. 

Dyspnoea severest at first, afterwards 
diminishing. 

Dullness distinctly circumscribed ; 
respiration bronchial, with moist rales 

A peculiar acid and alliaceous odor 
to the breath "like the smell of tinc- 
ture of horse radish." • (Gueneau de 
Mussy.) 



clots. 

Dyspnoea gradually grows in in 
tensity. 

Dullness larger and extending. 
Crepitant rale. 

Not present. 



PULMONARY EMBOLISM. 

The symptoms of an immediately fatal attack are: Sudden extreme 
dyspnoea with open tubes, cough and thoracic pain, lividity or pallor, 
rapidly failing pulse, cold sweats, intense anxiety, and attacks of faint- 
ing or unconsciousness, with or without spasms. 

In the diagnosis, the suddenness of the conditions being of the 
chief interest, all those forms of suffocation requiring time for their 
production may be disregarded, and there remain: 

1. Closure of the greater air passages or of a large number of small 
ones, from without or from within. 

2. Nervous lesions, particularly intra-cranial, affecting respiration 
and circulation. 

3. Obstruction to the pulmonary circulation from emboli, of blood 
and air particularly, fat being more gradual in its effects. 

Physical and rational evidence of open air passages eliminate the 



DISEASES OF THE RESPIRATORY SYSTEM. 



141 



first series. In intra-cranial origins of suffocation the predominant 
early symptoms are those of cerebral anaemia, namely, pallor, relaxed 
muscles, disturbed hearing and vision, contracted pupils, fainting and 
convulsions. Dyspnoea may sometimes precede these symptoms, but 
it is not of so severe a character as in the other series. 

In favor of the third is the history of an antecedent thrombus, or of 
a disease of the heart likelv to be associated with thrombosis. 



ASTHMA. 



Symptoms. 
There may be premonitory symp- 
toms such as gradually increasing 
dyspnoea or the passing of a large 
quantity of limpid urine ; but the at- 
tacks usually come on suddenly at an 
early hour in the morning ; the pa- 
tient awakes in a start, with a sensa- 
tion of suffocation and oppressiveness 
at the chest ; he either sits upright in 
bed, or sometimes stands holding on 
to a piece of furniture, so as to bring 
into play the accessory muscles of 
respiration. Countenance pale and 
anxious; in bad cases cyanotic. Skin 
covered with sweat; extremities cold. 
Pulse frequently feeble. The attacks 
generally terminate with the expulsion 
of tough, ashy grey pellets of mucus. 



Physical Signs. 
Chest greatly distended, though 
there is scarcely any expansive move- 
ment. Recussion of the intercostal 
spaces, supra-sternal and supra-clavic- 
ular fossae and epigastrium during in- 
spiration, which is short and jerky, 
while expiration is prolonged and 
wheezing. Vocal vibration not mark- 
edly affected. Rhonchal fremitus may 
be felt. Resonance on percussion in- 
creased all over the chest. Almost 
complete absence of vesicular mur- 
mur. Every variety and kind of sib- 
ilus and rhonchus, whistling, squeak- 
ing, cooing, snoring sounds, and oc- 
casionally mucous rales towards the 
termination. 



Post-mortem Appearances. — The appearances found after death 
are principally the result of chronic bronchitis and emphysema, 
with dilatation of the right side of the heart. 



PNEUMOTHORAX. 

This condition is generally found with serous effusions — pneumo- 
hydrothorax; but occasionally presents itself as an independent 
affection. The characteristics of the two forms are as follows : 



142 



DIFFERENTIAL DIAGNOSIS. 



Symptoms. 



Physical Signs. 



Pneumothorax. 



Pneumo-hydrothorax. 



Generally sharp, stabbing Symptoms as opposite, except 



pain, with the sensation of 
something having given 
way. Urgent dyspnoea 
and evidences of shock. 
More or less cyanosis. Pos- 
ture assumed by patient 
varies. Pulse frequent 
weak, and small. Respi 
ration may be 40 to 60 in 
the minute. Troublesome 
cough without expectora 
tion. In some cases of 
phthisis, or where there 
are extensive pleural adhe- 
sions, pneumothorax has 
come on quite impercepti- 
bly, and has only been 
discovered by physical ex- 
amination. 

• 
Dilatation of the affected 
side, with obliteration or 
bulging of the intercostal 
spaces. Movement on res- 
piration diminished or ab- 
sent. Increased elasticity 
of the walls of the chest. 
Feeble or absent vocal 
fremitus. Clear tympanitic 
resonance on percussion. 
If the amount of air is ex- 
treme there may be dull- 
ness. No true vesicular 
murmur ; bronchial breath- 
ing may be heard along 
the spine. Amphoric 
sounds, with inspiration, 
voice, and cough, also a 
metallic echo; the bell- 
sound may be elicited. 
The viscera are displaced 
to a variable degree. 



that the cough is usually at- 
tended by fetid, puriform 
expectoration. The patient 
lies on or towards the affected 
side. 



Same as in true pneumothorax, 
except that percussion is dull 
in the lower part of the chest, 
and tympanitic above the 
level of the fluid. Metallic 
tinkling and splashing sound 
on succussion are also fre- 
quently heard. 



DISEASES OF THE RESPIRATORY SYSTEM. 



143 



Post mortem 
appearance. 



Pneumothorax. 



Pneumo-hydrothorax. 



Lung collapsed, lying near 
vertebral column, unless 
bound down to old adhe- 
sions to some other part of 
the chest wall. The gas is 
composed chiefly of car-j 
bonic acid and nitrogen, 1 
and contains but little 
oxygen, and occasionally! 
some sulphureted hydro-: 
gen. 



Lung collapsed. Air, mixed 
with fluid, in pleural cavity. 
Mostly arises as a termination 
of phthisis, a superficial cavi- 
ty becoming ruptured. May 
occur in pneumonia, emphy- 
sema, or gangrene of the lung, 
and more rarely in other dis- 
eases. 



EMPHYSEMA. 

This affection presents itself in two forms, the vesicular and the 
interlobular, which are distinguished as follows : 



Vesicular Emphysema. 



Interlobular Emphysema. 



after some violent effort, the 
subcutaneous areolar tissue 
frequently becoming cedema- 
tous. 



Symptoms. Habitual shortness of breath, Urgent dyspnoea and oppression , 
with occasional paroxysms generally occurring suddenly 
of urgent dyspnoea, most 
frequently supervening on 
catarrh. Cough, with or 
without expectoration of 
thin, transparent, frothy; 
mucus. In the last stage 
of the disease there are 
symptoms due to interfer-j 
ence with the circulation, 
as palpitation, cyanosis, 
general dropsy, and con- 
gestion of the abdominal 
viscera. 



44 



DIFFERENTIAL DIAGNOSIS. 



Vesicular Emphysema. 



Interlobular Emphysema. 



Percussion tympanitic over the 
affected part. 



Physical signs.! Chest "barrel-shaped" and 
almost circular. Sternum 
projecting forward. Scap- 
ulae and clavicles raised 
and ill-defined. Ribs more 
horizontal and intercostal 
spaces widened Respira- 
tion abdominal. Move- 
ment of chest much di- 
minished. Heart beating 
in the epigastric region. 
Resonance on percussion 
greatly increased or tym- 
panitic. Feeble inspira- 
tion, prolonged expiration, 
the former wheezing, the 
latter generally with rhon- 
chus or sibilus. Vocal 
fremitus and resonance 
usually deficient. 

Post mortem i Lung does not collapse as 'Bead-like bubbles of air seen 



appearance. 



usual when the chest is 
opened, but, on the con- 
trary, may rise up and 
bulge out of its cavity. It 
is pale and anaemic, and 
does not crepitate when 
pressed, but feels soft and! 
downy, and is drier than! 
ordinary. The air-cells | 
are dilated, or several havej 
become one cavity from! 
the rupture of the septa 
between them. Cells vary 
from the size of a millet- 
seed to that of a swan-shot 
or larger. 



through the pleura, or parti- 
tions between the lobules 
much widened. Sometimes 
air is found beneath the areo- 
lar tissue of the neck. 



DISEASES OF THE RESPIRATORY SYSTEM. 1 45 



CANCER OF THE LUNG. 

The principal obstacle in recognizing this disease is the liability to 
confound it when primary and unilateral (as it usually is when primary) 
with phthisis. Similar cough, emaciation, haemoptysis, night sweats, 
etc., occur in both. The points of difference are: 



PULMONARY CANCER. 



PHTHISIS. 



Sides of chest more markedly asym- One side may be sunken ; never 
metrical; the tumor' may bulge bulging, 
through the intercostal spaces. 

Percussion dullness very great ; Percussion dullness moderate ; 
may extend beyond median line. I never extends beyond median line. 

Frequent changes in the signs 01 Changes much more gradual, 
auscultation, rales, bruits, etc. 

Hgemoptoic sputa, "resembling Sputa never present this appear- 
currant jelly." j ance. 

Pain constant, severe, lancinating. , Pain variable, intermittent. 

I 

Cancerous cachexia, tinge of skin, i A'bsent. 
etc. 

Pulmonary cancer is sometimes so masked, that its diagnosis re- 
quires the closest attention. It may be present without the charac- 
teristic sputa, without cachexia, and even without pain at cancerous 
spot.* Such instances are, of course, very rare. 

It is liable to be mistaken for chronic pleurisy, or vice versa. The 
distinguishing features are, that in cancer there is an absence of the 
complete consolidation of chronic pleurisy; the consolidation of the 
latter is at the lower portion of the lung ; the expectoration of cancer 
is quite different from that of pleurisy and bronchitis; and the pre- 
vious history, both of the individual and his family, in cancer points 
to this disease, while chronic pleurisy has as an antecedent an acute 
attack. 

* See case recorded in the Boston Med. and Surg. Journal, Jan., 1876. 
IO 



I46 DIFFERENTIAL DIAGNOSIS. 

The deposits of gummatous nodules in the lungs consequent on 
secondary syphilis, together with the cachexia attendant on that dis- 
ease, may stimulate a cancerous deposit The history of the case, 
the presence of syphilitic signs in other organs and tissues, and the 
fact that cancers tend to spread and infiltrate the surrounding tissue, 
while the syphilitic nodule remains isolated and circumscribed, are 
the distinctive points. 



CHAPTER III. 



DISEASES 

OF 

THE CIRCULATORY SYSTEM. 

Contents. — The Precordial Regions. Normal Sounds and Impulse of 
the Heart. Endocardial Murmurs. General Rules for the Diagnosis 
of Heart Disease. Constitutio?tal Symptoms of Heart Disease. Club- 
bing of the Fingers. Differential Signs Between Ancemic and 
Organic Blood Murmurs. Pain at and near the Heart. Aphorisms 
Regarding Angina Pectoris. Differential Signs of Aortic Obstruction 
a7id Aortic Incompetency ; of Mitral Obstruction aiid Mitral Incompe- 
tency ; of Pidmonary Obstruction and Tricuspid Regurgitation. Per- 
icarditis. Diagnosis Between Acute Endocardial aud Exocardial 
Sounds ; Between Cardiac Dilatation and Pericarditis with Effusion; 
Betwee?i Simple Hypertrophy, Hypertrophy with Dilatation, and 
Simple Dilatation. Fatty Degeneration of the Heart. 

The anatomical positions of the various members of the heart are 
as follows : 

THE PRECORDIAL REGIONS. 



Region. 



Situation. 



Apex of Heart. 

Base of Heart. 
Tricuspid Orifice. 



•Between fifth and six ribs on left side, about 
i two inches below the nipple and one inch 
on its sternal side. 

On a level with the third costal cartilages. 

Extends from the junction of the fourth left 
costal cartilage with the sternum, behind 
that bone to the articulation of it with the 
sixth right cartilage. 

(i47)~ 



148 



DIFFERENTIAL DIAGNOSIS. 



Region. 



Mitral Orifice. 



Pulmonary Orifice. 



Aortic Orifice. 



Situation. 



To the left of the tricuspid valves, immedi- 
ately behind the fourth costal cartilage. 

Immediately behind the left border of the 
sternum at the junction of the third costal 
cartilage with that bone. 

About half an inch lower than and to the 
right of the pulmonary orifice, behind the 
sternum, on a level with' the third inter- 
space. 



Let it be remembered that the tricuspid orifice is the most super- 
ficial, then the pulmonary, next the aortic, and deepest of all is the 
mitral orifice. Ranged from above downwards, the pulmonary orifice 
comes first, then the aortic, then the mitral, and lastly the tricuspid. 

PHYSICAL EXAMINATION OF PRECORDIAL REGION. 



Examination by 



Inspection. 



Palpation. 

Percussion. 
Auscultation. 



Shows. 



Form of chest. 

Point at which the apex of the heart strikes 

the wall of the chest. 
| Regularity of impulse, and extent over which 

it is perceptible. 

Force and regularity of impulse. 
Presence or absence of purring tremor or of 
friction fremitus. 

Extent and intensity of precordial dullness. 

Character of rhythm. 

" sounds, normal or abnormal. 



THE AREA OF SUPERFICIAL CARDIAC DULLNESS 
Is roughly triangular in shape, the right side of the triangle being 
the midsternal line from the level of the fourth chondro-sternal articu- 
lation downwards ; the hypothenuse being a line drawn from the same 
articulation to a point immediately above the apex-beat ; the base be- 
ing a line drawn from immediately below the apex-beat to the point 



DISEASES OF THE CIRCULATORY SYSTEM. 



149 



of meeting between the upper limit of liver dullness and the mid- 
sternal line (Dr. Gee). 

NORMAL SOUNDS'' AND IMPULSE OF HEART. 



Sound. 


Character. 


Point of 
greater in- 


Cause. 


Time. 


Condition of circula- 
tion. 






tensity. 






First Sound 


Dull and pro- 


Fourth and 


Closure of auri- 


4 
To" 


Contraction of ven- 


(Systolic). 


longed. 


fifth inter- 


culo-ventricular 




tricles, dilatation of 






costal 


valves, and, per- 




auricles. Closure 






spaces just 


haps, muscular 




of auriculo-ventri- 






within left 


contraction of 




cular valves, open- 






nipple line. 


the ventricles 
themselves. 




ness of arterial 
valves ; propulsion 
of blood into the 
arteries. Impulse 
of the heart im- 
mediately followed 
by pulse at the 
wrist. 


First Pause 








1 
To 


Auricles dilating. 


Second 


ihort and 


Base of heart, 


Sudden closure of 


2 
To" 


Dilatation of both au- 


Sound 


clear. 


opposi t e 


the aortic and 




ricles and ventricles. 


(Diastolic). 




the third 


pulmonary 




Closure of arterial 






costal carti- 


valves. 




valves, opening of 






lage. 






auriculo-ventricular 
valves. 


Second 












Pause. 








3 
TO 


Complete distension 
of auricles, followed 
by their contraction, 
and distension of 
ventricles. Auricu- 
lo- ventricular valves 
open, arterial valves 
closed. 


Impulse. 




Between fifth 

and sixth 
ribs on left 
side, about 
one and a 
half or two 
inches be- 
low the nip- 
ple. 


In part due to the 
tilting upwards 
of the apex, but 
chiefly to the 
change in shape 
of the heart, 
which during 
the systole be- 
comes harder 
and more glob- 
ular, and bulges 
forwards. 







150 



DIFFERENTIAL DIAGNOSIS. 



ENDOCARDIAL MURMURS. 



Time. 


Situation. 


Orifice. 


Nature. 


Systolic i 

2 

3 • 

4 • 
Diastolic i . 
Presystolic i . 


Basic. 

Apical. 

a 

Basic. 

Apical. 


Aortic. 

Pulmonary. 

Mitral. 

Tricuspid. 

Aortic. 

Mitral. 


Obstructive. 

u 

Regurgitant. ■ 
ti 

a 

Obstructive. 



Pulmonary regurgitant murmur (diastolic) and tricuspid obstruct- 
ive murmur (presystolic) are very rarely met with clinically, and for 
all practical purposes they may be disregarded. 

The most frequent combinations of these murmurs are: 

1. Combined aortic obstruction with regurgitation. 

2. Mitral obstruction and regurgitation. 

3. Various combinations of the two preceding forms, the* aortic and 
mitral valves being both diseased. 

4. Mitral obstruction with dilated right ventricle, and consequently 
tricuspid regurgitation (Dr. Aitken). 

Order of frequency of endocardial murmurs, commencing with the 
most common: 



1. Mitral regurgitant. 

2. Aortic constrictive. 

3. Aortic regurgitant. 

4. Mitral constrictive. 



5. Tricuspid regurgitant. 

6. Pulmonary constrictive. 

7. Pulmonary regurgitant. 

8. Tricuspid constrictive. 



Order of relative gravity as "estimated not only by their ultimate 
lethal tendency, but by the amount of complicated miseries they 
inflict."— Dr. Walshe. 

1. Tricuspid regurgitation. 

2. Mitral constriction and regurgitation. 

3. Aortic regurgitation. 

4. Pulmonary constriction. 

5. Aortic constriction. 



DISEASES OF THE CIRCULATORY SYSTEM. 1 5 I 

GENERAL RULES FOR THE DIAGNOSIS OF HEART DISEASE. 

Dr. John Hughes Bennett* gives the following rules : 
i. In health the cardiac dullness, on percussion, measures, immedi- 
ately below the nipple, two inches across, and the extent of dullness 
beyond this measurement commonly indicates either the increased 
size of the organ or undue distension of the pericardium. 

2. In health the apex of the heart may be felt and seen to strike the 
chest between the fifth and sixth ribs, a little below and a little to the 
inside of the left nipple. Any variations that may exist in the position 
of the apex are indications of disease either of the heart itself or of 
the parts around it. 

3. A friction murmur synchronous with the heart's movements, in- 
dicates pericardial or ex-pericardial exudation. 

4. A bellows murmur with the first sound, heard loudest over the 
apex, indicates mitral insufficiency. 

5. A bellows murmur with the second sound, heard loudest at the 
base, indicates aortic insufficiency. 

6. A bellows murmur with the second sound heard at the apex is 
rare. It indicates — 1st, Aortic disease, the murmur being propagated 
downwards to the apex; or, 2d. Roughened auricular surface of the 
mitral valves; or 3d, Mitral obstruction. 

7. A murmur with the first sound, loudest at the base, and propa- 
gated in the direction of the large arteries, is more common. It indi- 
cates — 1st, an altered condition of the blood, as in anemia; or 2d, 
Dilatation or disease or the aorta itself; or 3d, Stricture of the aortic 
orifice, or disease of the aortic valve. 

8. Hypertrophy of the heart may exist independent of any valvular 
lesion, but this*is rare. 

9. The pulse as a general rule is soft and irregular in mitral disease, 
but hard, jerking, or regular in aortic disease. 

10. Cerebral symptoms are more marked in aortic disease: pulmo- 
nary symptoms in mitral disease. 

Various constitutional symptoms should, in default of other obvi- 

*Lecttires on the Principles and Practice of Medicine. 



152 DIFFERENTIAL DIAGNOSIS, 

ous causation, lead to the suspicion of disease of the heart. These 
are mainly : 

I. Symptoms referred to the circulation. Violent, continued pulsation 
may arise from cardiac hypertrophy, and especially aortic regurgita- 
tion. Cyanosis, blueness of the lips, coldness of the finger-tips, etc., 
are common in many cardiac cases. Dropsy is a late and dangerous 
symptom. 

2. Symptoms referred to the Lungs. These are frequent cardiac com- 
plications, especially dyspnoea, orthopncea, and cough. 

3. Symptoms referred to the Brain. Vertigo, languor, chorea, epi- 
lepsy, apoplexy and paralysis may all be brought about by heart dis- 
ease. In sudden cerebral attacks in patients suffering with valvular 
disease, embolism is often at work. 

4. Stomach Symptoms. Dyspepsia and hemorrhoids may find 
their origin in cardiac lesions. 

5. Throat Symptoms. Pain in the throat is complained of in 
angina ; hoarseness and aphonia sometimes signify pericarditis. 

. 6. Renal Symptoms may follow heart disease. In all cases of car- 
diac disease the urine should be tested for albumen, as this condition 
may excite cardiac symptoms. 

CLUBBING OF THE FINGER ENDS IN CHRONIC HEART 
DISEASE AND PHTHISIS. 

The following aphorisms on this point are laid down by Dr. 
Horace Dobell.* 

Aphorism I. Clubbing of the finger-ends on one or both sides of 
the body, with or without incurvations of the nails, may occur when- 
ever the return of blood by one or both subclavian veins is seriously 
obstructed for a considerable length of time. 

II. Symmetrical clubbing of the finger-ends of both hands without 
incurvation of the sides and tips of the nails, is presumptive evidence 
of the existence of heart disease. 

III. Clubbing of the finger ends without incurvature of the sides and 
tips of the nails, is presumptive evidence against the existence of 
phthisis. 

* Affections of the Heart. London, 1 876. 



DISEASES OF THE CIRCULATORY SYSTEM. 



153 



IV. Symmetrical clubbing of the finger-ends conjoined with incurv- 
ation of the sides and tips of the nails, is a sign that obstruction of 
the return of blood by the subclavian veins and wasting of adipose 
tissue have co-existed. 



DIFFERENTIAL SIGNS BETWEEN ANAEMIC AND 

ORGANIC CARDIAC SOUNDS. 

ANEMIC SOUNDS. I ORGANIC SOUNDS. 

First sound heard over the right' First sound is soft ; is distinctly lo 
ventricle is rough, not distinctly lo- ■ cated at apex or base, 
cated at apex or base. 



Sounds vary in character. 



Sound the same after several exam- 
inations. 



Sounds increase in intensity in fol- Sounds diminish in intensity in re- 
lowing the aorta. ceding from the heart. 



Not affected by pressure. 



Not present. 



Pressure with the stethoscope in- 
creases or develops the sound. 

Bruit de diable, a continuous mu- 
sical hum, can be heard in the hollow 
above the right clavicle. 

Co-existence of pallor or anaemia; Co-existence of alteration in size cf 

amenorrhea ; leucorrhea ; nervous the heart ; other organic signs ; his- 

exhaustion ; chorea ; renal disease ; tory of rheumatism, 
phthisis. 



PAIN AT THE HEART. 

Pain is by no means a common symptom of heart disease. Not 
more than one in a dozen cases of chronic organic cardiac disease 
complain of pain at all.* In acute cardiac affections it is more fre- 
quent. In most cases of alleged pain at the heart it is found on ex- 
amination to proceed from dyspepsia, muscular rheumatism, inter- 
costal neuralgia, enlarged spleen, or the like. 

* SANSOM, Diagnosis of Diseases of the Heart, p. 3. 



154 DIFFERENTIAL DIAGNOSIS. 

DR. HORACE DOBELL'S APHORISMS REGARDING THE 

SIGNIFICANCE OF PAIN AT THE HEART AND 

IN ITS NEIGHBORHOOD.* 

APHORISMS. 

I. Pain in the region of the heart and down the left arm does not 
necessarily indicate heart disease. 

II. The conjunction of pain in the region of the heart and pain in 
the left arm may be a most important symptom of heart disease, and 
is never to be disregarded. 

III. If pain is excited by exercise, taken when the stomach is not 
distended with food or gas, and especially if it comes on quickly and 
ncreases steadily in severity with the continuance of exercise, it is 
almost certain there is some serious disease of the circulatory organs. 

IV. When it is found that flatulence or a full meal embarrasses the 
heart painfully, a careful investigation should be made into the con- 
dition both of the organ itself, and of the blood. 

V. Important heart disease may exist, and yet pain at the heart 
and in its neighborhood be absent. 

VI. The appalling import of pain in the throat in heart disease in- 
creases in proportion as the period of its onset deviates from the fol- 
lowing order of severity : 

1. Pain under the left breast. 

2. Pain extending from under the left breast to mid-sternum. 

3. Pain extending from mid-sternum towards the left shoulder. 

4. Pain extending from the left shoulder down the left arm. 

5. Pain extending from mid-sternum towards the right shoulder. 

6. Pain extending from the left shoulder down the right arm. 

7. Pain extending up the sternum towards the region of the throat. 

8. Pain in the thyroid cartilage. 

When this order of advance is maintained as the exciting cause is 
continued, pain in the throat expresses the degree of dangerous per- 
sistence in the exciting cause of heart distress, rather than the degree 
of danger in the disease itself. 

VII. In proportion as the right side of the chest and right arm take 

*On Affections of the Heart. London, 1876. 



DISEASES OF THE CIRCULATORY SYSTEM. 



5 



precedence in the order of extension of pain at the heart and its neigh- 
borhood, the probability increases that the aorta is more diseased than 
the heart. 

VIII. The volume of blood and other conditions being normal, the 
facility with which the pulse at the wrist is stopped by inspiration 
measures the loss of heart power. 

ANGINA PECTORIS. 
This disease is usually quoted as one typically connected with pain 
at the heart. This is by no means the case, as in many instances 
there is merely a sense of precordial distress, but no actual pain 
(Sansom). The diagnostic characters are : 

1. The attacks are paroxysmal, coming on at varying intervals and 
duration (from a minute to an hour), without assignable cause. 

2. There is always a sensation of coldness experienced, and often a 
cold sweat. 

3. The heart's action is not increased, and may be diminished. 

4. The chest is fixed and the breathing slow. 

5. The pain, when present, may be of great intensity, of a cold, 
sickening character, directly referred to the heart, with an accompa- 
nying sense of impending dissolution. 

Though a neurosis, angina pectoris distinctly points to some pro- 
gressive degeneration of the muscular texture of the heart. 

DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND 
AORTIC INCOMPETENCY. 



Aoitic Obstru:tion. 




Aortic Incompetency. 


Hypertrophy of left ven- 
tricle. 


Effect on Heart. 


Hypertrophy and dilata- 
tion of left ventricle. 


To left. 


Apex Displaced. 


Downwards and to left. 


To left greatly. 


Cardiac Dullness In- 
creased. 


Downwards and to left, 
more increased than in 
obstruction. 


Forcible; 


Impulse. 


More forcible than in ob- 
struction, and over 
wider area. 



i 5 6 



DIFFERENTIAL DIAGNOSIS. 



Aortic Obstruction. 



To left of sternum. 



Impulse, where ? 



Onward, ventriculo-aor- Murmur, its Direc- 
tic. 



Systolic; loudest at be- 
ginning of systole. 

Right border of sternum, 
in second intercostal 
space. 

Upwards to right sterno 
clavicular articulation 

Loud, harsh, or blowing. 



Replaces first at base. 



Depends on condition of 
valves, but aortic sec- 
ond sound generally 
feeble. 

Systolic ; in second right 
intercostal space. 



Normal, or perhaps de- 
creased. 
Diminished. 
Diminished. 
Regular. 
Slow. 

Arterial anaemia ; angina 
pectoris often present. 



tion. 
Murmur, Time, 



Point of Greatest In- 
tensity. 

Direction in which 
Propagated. 

Character of Sound 
(very uncertain 
and of little value 
for diagnosis). 

Relation to Normal 
Heart Sounds. 



Effect on Second 
Sound. 



Thrill. 

Effect on Pulse- 
Frequency. 

Volume. 
Power. 
Rhythm. 
Duration. 

General Tendency 
to 



Aortic Incompetency. 



To left of sternum. 

Backward ; aortic-ven- 
tricular. 

Diastolic • post-systolic ; 
loudest at beginning of 
diastole. 

Right border of sternum 
opposite third intercos- 
tal space. 

Downwards along ster- 
num and towards apex. 

Of higher pitch than in 
obstruction, and loud- 
ness decreases rapidly 
from commencement. 

Replaces seccnd at base, 
and occupies more or 
less of the pause. 

Apparent intensification 
of pulmonary second. 



Down sternum ; diastolic. 

Visible pulsation in arter- 
ies (locomotive pulse). 

Normal, or perhaps de- 
creased. 
Increased. 
Increased. 
Regular. 
Quick. 

As in obstruction, but 
sudden death more 
common than in any 
other form of valvular 
disease. 



DISEASES OF THE CIRCULATORY SYSTEM. 



157 



DIFFERENTIAL SIGNS BETWEEN MITRAL OBSTRUC- 
TION AND MITRAL INCOMPETENCY. 



Mitral Obstruction. 



Hypertrophy and dilata- Effect on Heart, 
tion of left auricle and 
right chambers. 



To left and slightly 
downward. 

To right of sternum, also 
to left at base, greatly. 



Feeble, undulating, and 
diffused. 

To right of sternum and 
in epigastrium. 

Onward ; auriculo- ventri- 
cular. 

Diastolic, presystolic, 
loudest at termination 
of diastole. 

A little within and up- 
wards from apex beat. 

Upwards and inwards to 
wards right base. 



Generally rough and 
harsh. 



Immediately precedes the 
first at apex, which is 
often very loud. 



Apex Displaced. 



Cardiac Dullness In- 
creased. 



Impulse. 



Impulse, where ? 



Murmur, its Direc- 
tion. 

Murmur, Time. 



Point of Greatest 
Intensity. 

Direction in which 
propagated. 



Mitral fticompetency. 



Hypertrophy and dilata- 
tion of all four cham- 
bers. 

To left and downward. 



To right of sternum, and 
also to left and down- 
wards. 



Most of all. 



Generally increased all 
over cardiac region. 

Backward; ventriculo-au- 
ricular. 

Systolic, loudest at begin- 
ning of systole. 



A little outwards and up- 
wards from apex-beat. 

Upwards towards left 
base, and backwards 
into axilla, and behind. 



Character of Sound Blowing, bellows mui 
(very uncertain 
and of little value 
for diagnosis). 

Relation to Normal Replaces first at apex. 
Heart Sounds. 



i 5 8 



DIFFERENTIAL DIAGNOSIS. 



Mitral Obstruction. 



Intensification of pulmo- 
nary second. 

Presystolic ; upwards and 
inwards from apex. 



Increased. 
Diminished. 
Diminished greatly. 
Very irregular. 
Quick. 

Pulmonary and venous 
congestion and slow 
death by asphyxia. 



Effect on 
Sound. 



Second 



Mitral Incompetency. 



Thrill. 

Effect on Pulse. — 

Frequency. 

Volume. 

Power. 

Rhythm. 

Duration. 

General Tendency 
to 



Intensification of pulmo- 
nary second. 

At apex and towards ax- 
illa. 



Increased. 

Somewhat diminished. 
Diminished a little. 
Somewhat irregular. 
Nearly normal. 

As in obstruction. 



DIFFERENTIAL SIGNS BETWEEN PULMONARY OB- 
STRUCTION AND TRICUSPID REGURGITATION. 



Pulmonary Obstruction. 



Systolic, onward, ventric- 
ulo-pulmonary. 

Left border of sternum, in 
second interspace. 

Generally ansemia. Some- 
times pressure of solidi- 
fied lung (phthisical or 
pneumonic) upon the 
artery. Rarely organic, 
and then usually con- 
genital. 

Frequently Bruit de dia- 
ble in the jugular veins. 



Murmur. 



Point of greatest in- 
tensity. 

Cause. 



Associated Signs. 



Tricuspid Regurgitation. 



Systolic, backward, ven- 
triculo-auricular. 

Base of ensiform cartilage. 



Generally secondary to 
disease of the lung or of 
left side of the heart. 



Systolic pulsation of the 
distended jugular 
veins. 



DISEASES OF THE CIRCULATORY SYSTEM. 



159 



PERICARDITIS. 



Stage. 



1 st stage. 

(Inflammation 
without effu- 
sion). 



Symptoms. 



Physical Signs. 



If occurring during the Greater extent of visible impulse 



2d stage. 
(With effusion). 



course of acute rheu- 
matism the disease 
may come on insidi- 
ously. 
Pain and tenderness in 
the cardiac region. 
Palpitation. Increased 
frequency of the pulse. 
Shortness of breath. 
Anxiety. Pyrexia. 



than natural, and on palpation 
the impulse is found to be more 
forcible, but unequal. Fric- 
tion fremitus rare. Area of dull- 
ness not altered. Single or dou- 
ble friction sound, often pre- 
ceded by a cantering action of 
the heart.* Heart sounds maybe 
unchanged or even louder than 
in health, or they may be masked 
bv the friction sounds. 



Lesspain. Pulse small. Bulging of the praecordial region. 



frequent, and some 
times irregular. Dysp 
ncea and often orthop 
ncea. Irritable cough 
Loss of voice. Dys 
phagia. Fulness of 
veins in the neck 
Duskiness of complex- 
ion. Great anxiety. 
Sleeplessness. Deli- 
rium. 



3d stage. 
(Resolution). 



Impulse displaced upwards and 
outwards ; undulatory. On pal- 
pation, feeble and sometimes not 
perceptible ; irregular. Area of 
cardiac dullness increased, first 
noticed at the base of the heart, 
and afterwards extending to left 
of apex beat, increased by the 
recumbent posture. Heart 

sounds feeble, distant and muf- 
fled at apex, louder and more 
superficial at base. Friction may 
or may not be heard. 



A gradual subsidence of. Diminution of the dullness from 
the symptoms of the above and laterally. Heart 
second stage. sounds become clearer. Friction 

sounds may be heard with in- 
creased intensity. 



Post-mortem Appearances. — 1st. Pericardium is dry, inflamed and 
has lost its polish. Exudation of lymph on both surfaces, but more 
on the visceral. The membrane may have a shaggy appearance. 

*Cantering action of the heart, beside being met with in commencing pericarditis, is also 
caused by reduplication of the first or second sound of the heart against the thoracic wall at 
the moment of diastole, generally due to pericardial adhesions. 



l60 DIFFERENTIAL DIAGNOSE. 

2d. Fluid in variable quantity in the sac of the pericardium. 
Usually serofibrinous, containing floculi of lymph. It may be pur- 
ulent or blood stained. 

3d. Organized lymph on the pericardium with or without adhesions 
between the two surfaces, which may be intimately adherent or united 
by mesh-like adhesions. 

The Pain of Pericarditis. — Rheumatic pericarditis is more or less 
painful ; but secondary pericarditis developing in the acute stage of 
inflections or the chronic period of cachectic diseases, is invariably 
painless. 

The pain is usually nearly equal on both sides of the chest ; or it 
remains localized at the precordial region, at the epigastrium, or at 
the left side of the xyphoid cartilage. In these positions the pain is 
peripheric, and its intensity does not increase the danger of the peri- 
carditis. But when the pain is central, giving rise to disturbance of 
circulation and respiration, and simulating that of angina pectoris, it 
means acute inflammation of the cardiac nerves, and marks an excep- 
tionally bad case of pericarditis.* 

DIAGNOSIS BETWEEN ACUTE ENDOCARDIAL AND 
EXOCARDIAL (PERICARDIAL) SOUNDS. 

The sounds respectively perceptible in endocarditis and pancarditis 
and allied disorders, may be discriminated by the following table : 

ENDOCARDIAL. EXOCARDIAL. 



1. A blowing sound, soft and bel- 
lows-like ; not affected by pressure. 



1. A creaking, rubbing, rough, to- 
and-fro sound, intensified by pressure 
of the stethoscope and by the patient 
bending forwards. 



2. A thrill may be felt on palpation. J 2. On palpation friction fremitus 

may be felt. 



3. The sound appears distant. 



3. The sound appears near. 



4. May exist only with the systole j 4. Exists with diastole as well as 
or the diastole. I systole. 

* Dr. Wertheimer, These de Paris, 1876; DobeWs Reports. 



DISEASES OF THE CIRCULATORY SYSTEM. 



16: 



ENDOCARDIAL. EXOCARDIAL. 

5. Accompanies the heart sounds. 5. Does not correspond with the 

rhythm of the heart. 

6. Heard along the course of the 6. Confined to the region of the 
great vessels, or conducted round to heart and limited to site of production, 
the back. 



7. Persistent character. 



7 Rapid and frequent change in 
character ; here to-day and gone to- 
morrow. 



8. Area of cardiac dullness not al- 8. Increased area of dullness, if fluid 
tered. be also present. 



DIFFERENTIAL SIGNS OF CARDIAC DILATATION 
AND PERICARDITIS WITH EFFUSION. 



CARDIAC DILATATION. 

Dullness increased in the hori- 
zontal axis, of a square outline. 

Heart sounds feeble but clear. 



PERICARDITIS WITH EFFU- 
SION. 

Prsecardial dullness extends upward 
and is of a pyramidal outline, with 
apex above. 

Heart sounds feeble, and distant 
sounding. 

Transition from dullness to lung 
resonance abrupt. 

Occasionally friction sound. 

Limits of dullness often vary from 
day to day or week to week. 

Apex heat some distance above 
lower limit of cardiac dullness. (San- 
som) 

There is no doubt but that the general rules laid down for diagnos- 
ing pericardial effusion have been too vague. Dr. T. M. Rotch, of 
Boston, has lately re-examined the subject, and succeeded in fixing 
a more perfect diagnostic sign than any hitherto mentioned. He 
shows that an area of flatness, at from two to three centimeters from the 
11 



Transition from dullness to lung 
resonance more gradual. 

No friction sound. 

Limits of dullness persistent. 



Apex heat felt at lower limits of car- 
diac dullness. 



1 62 



DIFFERENTIAL DIAGNOSIS. 



right edge of the sternum in the fifth intercostal space, is almost abso- 
lutely sufficient to mark the presence of an effusion, and differentiate 
it from enlarged heart.* 

DIFFERENTIAL SIGNS OF SIMPLE HYPERTROPHY. 



Palpation. 



Percussion. 



Auscultation. 



Pulse. 



General symp- 
toms. 



Simple Hypertrophy. ^^Jtion. 



Cardiac area extend- 
ed. Impulse strong, 
lifting, or forcing. 



Dullness increased lat- 
erally and down- 
wards. 

First sound dull, pro- 
longed, intensified ; 
second sound inten- 
sified. No respira- 
tory murmur over 
praecordium. 



Extent of visible 
impulse great- 
ly increased. 
Action regular 
strong. 



Simple Dilatation. 



Extent of impulse 
greatly increased, 
but feeble, without 
lifting or forcing 
character. 



Dullness lateral Dullness increased 



and down- 
wards. 

Both sounds pro- 
longed. 



Strong, full, 
pressible. 



incom-jLess strong, vari- 
able. 



Fullness in the head, 
epigastric weight, 
short breath, rarely 
debility ; Bright's 
disease. 



the horizontal 
of the heart. 



axis 



Both sounds short, ab- 
rupt, feeble. Feeble 
respiratory mur- 
mur. 



Weak, compressible, 
irregular. 

Dyspnoea, cough, pal- 
pitation, portal con- 
gestion, debility, 
ascites. 



FATTY DEGENERATION OF THE HEART. 

This condition of the heart is frequently associated with dilatation. 
Generally the area of praecordial dullness is normal or slightly in- 
creased ; the impulse weak ; the apex beat indistinct ; the action 
irregular ; the first sound short and feeble ; the second prolonged and 
intensified ; pulse is irregular. 



* Medical Communications of the Mass. Medical Society. 1878. 



DISEASES OF THE CIRCULATORY SYSTEM. 1 63 

These physical signs obviously offer very little ground for a diag- 
nosis. Of rational signs the following have been mentioned : 

1. Attacks of faintness attended with sensations of great coldness, 
recurring without obvious cause. (DaCosta.) 

2. Arcus senilis. For this to be significant of cardiac degeneration, 
the ring must be ill-defined, rather yellowish than white, and the rest 
of the cornea be slightly cloudy or opaque, not clear and translucent, 
a tinge of jaundice being present. When this is the case, "the 
chances of cardiac degeneration are formidable." (Sansom.) 

3. Paroxysms of severe pain across the upper part of the sternum, 
and in the region of the heart. 

4. Stomach derangements, accompanied sometimes by constipation, 
but more generally by diarrhoea and frequent vomiting. This Dr. L. 
H. J. Hayne thinks " almost pathognomonic of this disease." {Lancet, 
January, 1875.) 

5. The " Cheyne-Stokes " Respiration of ascending and descend- 
ing rhythm is present in about one-third of the cases, and is probably 
dependent on atheroma of the aorta. (Hayden.) This symptom was 
first described in a case by Dr. Cheyne, in 18 18, as follows : 

" For several days his breathing was irregular ; it would entirely 
cease for a quarter of a minute; then it would become perceptible, 
though very slow ; then, by degrees, it became heaving and quick ; 
and then it would gradually cease again. This revolution in the state 
of breathing occupied about a minute, during which there were about 
thirty acts of respiration." In this case fatty disease of the heart was 
very marked, while the valves were healthy, and the aorta was "stud- 
ded with steatomatous and earthy concretions." 

No general attention, however, was directed to the peculiarity and 
striking character of this symptom, until, in 1846, Dr. Stokes urged 
its significance as a sign of fatty degeneration of the heart, believing 
that its presence was pathognomonic of this affection, and that it 
always betokened a fatal and not far distant termination. That it did 
not necessarily depend on fatty degeneration of the heart itself, was 
soon shown by Dr. Seaton Reid, who described a case in which the 
muscular structure was healthy, while the mitral and aortic valves 
were both incompetent, the left ventricle was hypertrophied, and the 



164 DIFFERENTIAL DIAGNOSIS. 

aorta dilated and atheromatous. It remains an important and signifi- 
cant, if not pathognomonic sign. 

Dr. Hayden is of opinion that the absence of the impulse, or its 
extremely feeble character; the brief duration of the first sound, 
whether marked or sharp, in primary cases, and its almost complete 
or absolute extinction in those preceded by hypertrophy ; the restric- 
tion of the sounds within a very limited area ; and the occasional 
irregularity of the heart's action, will suffice, in the majority of cases, 
to establish the diagnosis of fatty heart from the physical signs alone. 
He adds that the incipiency of primary fatty degeneration may be 
suspected, if the pulse, previously regular, becomes weak and irregu- 
lar; if the surface be pale, the patient subject to dizziness or syncope, 
and the cardiac impulse feeble ; although the sounds of the heart 
may not appreciably differ from their normal character. 



CHAPTER IV. 

DISEASES OE THE DIGESTIVE SYSTEM. 

The Stomach and Bowels. Principal Symptoms. The Tongue. The 
Appetite. Acidity (i) from Fermentation, (2) from Hypersecretion. 
Pain. Flatulence. Vertigo, (1) Stomachal, (2) Cerebral. Vomiting, 
(1) Stomachal, (2) Cerebral. Comparison of Atonic Dyspepsia, 
Chronic Gastritis, Gastric Ulcer and Gastric Cancer. Indigestion 
or Dyspepsia. Abdominal Phthisis. Obstruction of the Bowels, En- 
teritis and, Colitis. 

The Liver. Method of Examination. Significance of Pain in the 
Liver. Significance of Jaundice. Jaundice with Obstruction. Jaun- 
dice without Obstruction. Diseases Characterized by Enlargement 
with Smooth Surface ; Enlargement with Uneven Surface ; with Di- 
minution of the Organ. Hepatic Abscess. 

Internal Parasites. Tape-worm. Hydatids. Round W^rms. 
Thread Worms. Trichinosis. 

DISEASES OF THE DIGESTIVE SYSTEM. 
The principal symptoms to which the attention is directed in the 
diagnosis of diseases of the digestive organs are those connected 
with the tongue, the appetite, acidity, vomiting, flatulence, vertigo 
and pain. 

THE TONGUE. 

Late writers have shown considerable skepticism on the accuracy 
of the appearance of the tongue as indicative of the condition of the 
lining membrane of the stomach. It is true that a white and furred 
or a red and cracked tongue is occasionally seen in healthy sub- 
jects ; but the standard of comparison should not be an ideally 
clean tongue, but the condition of the organ in the patient under 

(165) 



1 66 DIFFERENTIAL DIAGNOSIS. 

inspection when in health. Local causes, such as carious teeth and 
irritating agents (tobacco, tea, mercury, etc.), must be allowed for in 
the examination. When these and similar considerations are weighed 
together with the repeated instances of simultaneous affections of the 
stomach and tongue revealed by post mortems, no question remains 
that the latter organ often is of high diagnostic worth. 

Dr. Robert Farqharson states in a recent lecture on the diagno- 
sis of dyspepsia,* that in his experience, the class of tongue which 
coincides most commonly with digestive disturbance, is that in which 
the tongue seems to be covered with a thin, white fur, which on mi- 
nute inspection is seen to be composed of a series of minute raised 
dots, and this usually coincides with pain immediately following 
meals. 

If the tongue is raw and quite stripped of epithelium, with en- 
larged and prominent papilla, as we often see in phthisis, pain im- 
mediately after food and vomiting, are usual symptoms, or large, 
red papillae may stand in bold relief through a pale coating, or the 
tongue may be simply large and pale and flabby, as though too big 
for the mouth. 

Dr. Wilson Fox specifies the following conditions of the tongue as 
valuable aids to diagnosis in this class of diseases : 

Dyspepsia with distinct atony of the stomach. The tongue broad, pale, 
and flabby, the papillae generally enlarged, more especially on the tip 
and edges. 

Dyspepsia from irritative causes. The tongue is redder than usual, 
often of a bright florid color, or even raw looking. It is often pointed 
at the tip, which, together with the sides, presents an extreme degree 
of injection, the papillae standing out as vivid red points. This form 
is often associated with aphthae, and is most common in scrofulous 
children and phthisical adults. 

Dyspepsia from excessive or hurried eating, is apt to present a tongue 
uniformity covered throughout the greater part of its surface with a 
thick fur, whitish or brownish, with some degree of enlargement and 
redness of the papillae at the tip and edges. 

* Medical Press and Circular. July, 1877. 



DISEASES OF THE DIGESTIVE SYSTEM. l6j 

Neuroses of the stomach display a tongue which, as a rule, is clean, 
though often pale, broad and flabby. 

THE APPETITE. 

Anorexia, or loss of appetite, is observed in cancer, in most inflam- 
matory states of the stomach, in obstinate constipation, as well as in 
the pyrexial state. 

Boulimia, or excessive appetite, is found associated with enlargement 
of the stomach, in duration of itscoats, also in diabetics and various 
forms of mental alienation. 

Capricious and depraved appetite is met with in sufferers from intes- 
tinal worms, in some cases of chronic inflammation of the stomach, as 
well as in chlorosis, pregnancy and hysteria. 

ACIDITY OF THE STOMACH, (i) FROM FERMENTATION, 
(2) FROM HYPER-SECRETION. 

Acidity of the stomach, pyrosis, heartburn, and water-brash, are dis- 
turbances of the digestion frequently included in one category. In all, 
an excessive amount of acid is formed in the stomach; but in some 
cases the origin of the acid is to be sought in fermentative action, and 
in others in hypersecretion from the coats of the stomach, thus calling 
for different lines of treatment. 

In both forms the process of digestion is impaired, but to a more 
marked degree in the fermentative variety, in which also as a natural 
consequence the impairment of nutrition of the patient is more ob- 
vious. As the fermentative action interferes with the functions of the 
liver, the stools are apt to be pale, and the patient suffer from consti- 
pation. The frequency with which attacks of gout and rheumatism 
are preceded by this form of acidity points to a diathetic process 
involving the general constitution. 

The following differential table, based on one given by Dr. Wilson 
Fox, exhibits in a concise form the distinction between the two forms 
of acidity : 



6$ 



DIFFERENTIAL DIAGNOSIS. 



ACIDITY FROM FERMENTA- 
TION. 

Occurs in connection with causes 
which impede digestion. 



Usually attains its height some 
hours after food, and is more marked 
in proportion to the size of the meal, 
and inversely to the digestive powers. 

Flatulence is common. 

Pain not severe, and but slightly or 
not at all relieved by eating. 



Vomiting is rare. 

Vomited matters may con ain or- 
ganic acids, torulae and sarcinse. 

Urine frequently shows an alkales- 
cent reaction. 



ACIDITY FROM HYPER-SECRE- 
TION. 
Is most common as a reflex symp- 
tom, or in connection with other ner- 
vous disturbance, or with ulcer and 
cancer of the stomach. 

Occurs in the empty stomach, or 
rapidly after food, and is often of 
great intensity after a small meal. 



Flatulence is rare. 

Pain more severe, most felt when 
the stomach is empty, and is relieved 
by food. 

Vomiting is common. 

Vomited matters apt to show hydro- 
chloric acid in excess. 



Urine rarely alkaline. 



PAIN. 
Pain in the stomach is indicative of one of the following conditions: 

1. The presence of irritating foreign bodies, as mechanical sub- 
stances, corrosive poisons, blood or bile in large quantities, inflation 
from air or gases, etc. 

2. Organic diseases altering the anatomical structure of the coats, 
especially gastritis, chronic ulcer, cancer and thickening of the pylorus. 

3. Perverted secretions, as in acidity. 

4. Perverted innervation, which may be a local neurosis, as in forms 
of dyspepsia where pain is the prominent symptom, or as in cramp of 
the muscles of the stomach ; or it may be from general disorders, as 
in patients of a rheumatic or gouty diathesis ; or it may be referable 
to the general nervous system, as in pure neuralgia of the stomach 
and hysteria. 

Pain in the stomach must be distinguished from rheumatic and 



DISEASES OF THE DIGESTIVE SYSTEM. 1 69 

other pains in the abdominal muscles immediately over the stomach. 
In the latter the superficial tenderness is much greater; it is usually 
more marked in the left recti and obliqui abdominis muscles, and 
especially near their attachment to the ribs, where moderate pressure 
cannot affect the stomach, and by its independence of the digestive 
acts (Bricquet). 

Pain in the stomach is also liable to be simulated by pain in the 
course of the transverse colon, especially when the colon is dis- 
tended with gas. The diagnosis may usually be made by gentle 
percussion, the note arising from tapping a distended colon being 
less prolonged and of a higher pitch than that elicited from the 
stomach. The pain from the colon is also less felt at the ensiform 
cartilage than in the hypochondriac regions, and often extends to- 
wards the sigmoid flexure, and is associated with other signs of in- 
testinal flatulence. 

Pain in the stomach depending on diseases of the spinal cord is 
distinguished by its superficial tenderness, by the presence of other 
painful points in the affected nerve, and by the co-existence of other 
nervous, and the absence of digestive symptoms. 

FLATULENCE AND ERUCTATION. 

Dyspeptics generally suffer from gases in the stomach, producing 
eructations. These gases are either generated from imperfectly di- 
gested food, or are secreted from the capillaries. 

Eructations having the taste or odor of spoiled eggs, and occur- 
ring during the process of digestion, indicate the presence of sul- 
phureted hydrogen from the decomposition of food. 

When the eructations are odorless, and occur chiefly in an empty 
state of the stomach, they indicate a gaseous secretion of carbonic 
acid, hydrogen or nitrogen from the coats of the capillaries. 

In the former case the indications are to use anti-ferments; while 
in the latter relief is often attained by simply regulating the hours 
of meals, so as to avoid long intervals between the times of taking 
food. 



I/O DIFFERENTIAL DIAGNOSIS. 

VERTIGO. 

Stomachal vertigo is not unfrequently difficult to distinguish as 
such, because in all severe vertigoes the stomach is disturbed. In 
undoubted examples the vertigo always bears some distinct relation 
to the condition of the stomach, coming on only when that organ is 
full, or only when it is empty, or only after certain articles of food, 
as shell-fish, strawberries, coffee, fresh bread, etc. There are also 
generally some dyspeptic symptoms other than vertigo complained 
of. Some other points are mentioned in the following table: 

STOMACHAL VERTIGO. I CEREBRAL VERTIGO. 

Usually appears in definite relation J Occurs without relation to the tak- 
to taking food ; either after a meal, j ing of food, 
after particular ingesta, or on an empty 
stomach. 

Generally occurs in middle life. Occurs in advanced life. 

The apparent motion is felt to be A sense of movement or actual turn- 
subjective, not real (Gowers). ing of objects. 



Special senses not involved beyond j Deafness and tinnitus aurium often 
perverted vision. Consciousness never i present. Sometimes loss of conscious- 
lost. ' ness. 

VOMITING, (i) FROM DISEASE OF THE STOMACH, 
(2) FROM DISEASES, OF THE BRAIN. 

Persistent vomiting is a frequent symptom of obstinate gastric dis- 
turbance ; and it has also been frequently noted as a«symptom asso- 
ciated with organic disease of the brain and cord, not unfrequently 
masking them and diverting the attention of the practitioner from the 
real seat of lesion. Thus in suddenly induced cerebral anaemia, in 
the commencement of the paralysis which follows diphtheria, in 
tubercular meningitis, in concussion of the brain, in poisoning affect- 
ing the brain and cord, and in fact in almost any disease of the cere- 
bral centers, it is possible that one of the earlier and most prominent 
symptoms will be obstinate vomiting. 

In a general way it may be stated that vomiting arising from the 
stomach is attended with more or less pain, with a furred tongue, 



DISEASES OF THE DIGESTIVE SYSTEM. IJl 



with constipation or diarrhoea, sense of weight at the epigastrium, and 
preceded for a considerable period by a sense of nausea. 

Vomiting from cerebral causes on the other hand is usually char- 
acterized by an absence of these symptoms, by a clean tongue and a 
history of freedom from digestive disturbance. 

Dr. Romberg has given the following criteria for the discrimination 
of vomiting of cerebral origin : 

1 . The influence of the position of the head ; the vomiting is arrested 
in the horizontal, and recurs and is frequently repeated in the erect 
position. 

2. The prevailing absence of premonitory nausea. 

3. The peculiar character of the act of vomiting; the contents of 
the stomach are ejected without fatigue or retching, as the milk is re- 
jected by babies at the breast. 

4. The complication with other phenomena, the more frequent 01 
of which are pains in the head, and irregularity of the cardiac and 
radial pulse, increased during and subsequent to the act of vomiting. 

The following differential table further exhibits the points of con- 
trast (from Dr. W. Fox) : 

GASTRIC VOMITING. I CEREBRAL VOMITING. 

Epigastric pain and tenderness are | Epigastric pain and tenderness are 
common, and in some cases very I rare. 



marked. 

Nausea is constant. 



Nausea is frequently absent. 



Oppression and weight at the epi- These are rare, 
gastrium are constant. 

Bowels are variable. Bowels are constipated. 

The tongue is' loaded, except in cer- The tongue is usually clean, 
tain cases of cancer or ulcer. 

Headache is absent, or not intense? Headache often violent, the inva- 

chiefly frontal, of gradual invasion, sion sudden, and not relieved by 
and relieved by the vomiting. | vomiting. 



172 



DIFFERENTIAL DIAGNOSIS. 



GASTRIC VOMITING. 

Vertigo is rare and relieved by 
vomiting. 

Other nervous phenomena are rarely 
present, and then only in slighter 
forms, and relieved by vomiting. 



CEREBRAL VOMITING. 

Vertigo is very frequent and not 
relieved by vomiting. 

Indistinctness of vision and diplo- 
pia. Confusion of ideas. Loss of 
memory. Not relieved by vomiting. 
Anaesthesia or paresthesia, paralysis or 
cramp, convulsion or coma, are com- 
mon or soon supervene. 



NATURE OF VOMITED MATTERS. 

The indications derived from the nature of the matters thrown up 
in vomiting are as follows : 

Ingesta. The food is returned unaltered, or but slightly changed, 
in nervous vomiting; in a half digested state and strongly acid in 
chronic inflammation and cancer of the stomach ; mixed with the 
microscopic forms known as sarcinse and torulae in chronic gastritis, 
gastric ulcer and cancer. 

Mucus is vomited in a catarrahal or sub-inflammatory condition of 
the stomach. 

Bile appears whenever the retching is long and violent, and does 
not indicate any special disease. 

Pus is not formed in the stomach, and when present in the vomit 
indicates disease in the esophagus. 

Fceces also indicates a disease elsewhere than the stomach, usually 
an obstruction of the intestinal canal. 

Blood is thrown up in gastric cancer and ulcer, in severe gastritis, in 
external injuries, vicariously of the uterus, and frequently from dis- 
ease of the heart or liver, producing distension of the capillaries. 
The presence of blood directly proceeding from the stomach, says Dr. 
Fox, if accompanied by severe pain, is almost pathognomonic of either 
gastric ulcer or cancer. • 



DISEASES OF THE DIGESTIVE SYSTEM. 1 73 

ATONIC DYSPEPSIA, INFLAMMATORY DYSPEPSIA, 
GASTRIC ULCER, GASTRIC CANCER. 

The chief points in the diagnosis of diseases of the stomach are 
those connected with the differentiation of simple dyspepsia (atony of 
the stomach), inflammatory dyspepsia (gastritis, gastric catarrh, ca- 
tarrhal inflammation of the stomach), gastric ulcer and gastric cancer. 

From this group the nervous disturbances of the stomach are 
broadly marked off by the superficial character of the pain in these 
latter, its independence of the acts of digestion and the nature of the 
food, the co-existence of other neuralgise, the frequent absence of ema- 
ciation and other disturbances of nutrition, and the sex and age of the 
patients. 

The following comparative table drawn from the works of Drs. W. 
Fox, William Brinton, and Da Costa, illustrates the main points of 
difference in the four diseases named : 



174 



DIFFERENTIAL DIAGNOSIS. 



ATONIC DYSPEPSIA. 

No pain or soreness at the epigas- 



CHRONIC GASTRITIS. 
Pain at the epigastrium somewhat 
trium." Sensation of weight or 'load, augmented by food; also soreness, 
rather than tenderness. j Both constant, though not severe. 



Symptoms of indigestion. Appetite 
impaired. Thirst generally absent. 
Tongue pale and flabby. 

Vomiting rare. 



No hemorrhage. 

Bowels may be regular. 

No febrile symptoms 

Nutrition not materially interfered 
with. 

Not confined to any age. 



Indigestion present. Appetite ca- 
pricious. Thirst increased. Tongue 
furred and red at edges. 

Sometimes vomiting. 



Hemorrhage absent, or rare and 
trifling. 



Bowels constipated. 

Occasional slight pyrexia (Fox). 

Slight emaciation ; slightly earthy 
tint to skin (Fox). 

More common in middle or ad- 
vanced life. 



Course of disease uniform ; may be Disease with marked exacerbations 
cured, and remissions. May be relieved or 

cured. 



No tumor. Percussion resonant. 



No tumor. Percussion resonant. 



DISEASES OF THE DIGESTIVE SYSTEM. 



75 



GASTRIC ULCER. GASTRIC CANCER. 

Pain at the epigastrium much ; Pain paroxysmal, radiating, often 
augmented by food ; is intermittent ; ! severe and lancinating j rarely remit- 
subsides after digestion ; pain in pa- ; ting ; never intermitting ; little or not 
roxysms, but not lancinating ; epigas- ' at all affected by food ; not always 
trie soreness strictly localized. Some- accompanied by soreness, 
times a painful spot over lower dorsal ' 
vertebra 



Symptoms of indigestion slight. 



Symptoms of indigestion more 
marked. Extreme acidity of the 
stomach. 



Vomiting may be present or not. 
Usually relieves the pain. 

Abundant haematemesis. 



Bowels slightly or not constipated. 

No fever present. 

Frequently extreme pallor and de- 
bility. 

May occur in middle-aged persons, 
but is frequently seen in young adults, 
especially females. 

Duration uncertain ; may get well; 
may run on rapidly to perforation ; 
or may last for years. 

No tumor. Percussion resonant. 



Vomiting a very frequent symptom. 
Does not relieve the pain. 

Hgematemesis not very abundant ; 
but occasioning frequently vomiting of 
a substance resembling coffee grounds. 

Constipation obstinate. 

Fever not uncommon. 

Gradual and progressive loss of 
flesh and debility. 

Most common in elderly people ; 
■ rarely occurs in persons under forty 
I years of age. 

Duration about one year ; very 
rarely reaches two. Termination 
fatal. 

Generally a tumor. Percussion 
variable. 



I76 DIFFERENTIAL DIAGNOSIS. 

In reference to the value of percussion in diagnosing gastric cancer, 
Professor Peter, of Paris, has directed attention to the fact that when 
superficial percussion, percussion en dedolant, is made over the stom- 
achal region somewhat distended by gas, there is found at certain 
points, especially m the region of the greater curvature, a certain 
obscurity of the note alternating with the zones of sonority. But 
this sign is absolutely wanting on deep percussion such as is ordinar- 
ily employed. Prof. Peter, by this means, diagnosed a cancer of the 
stomach situated at the posterior surface of the greater curvature, 
with some cancerous nodules probably disseminated through the 
epiploon below the splenic region and also in the hypogastric region. 
At this last point also superficial percussion gave the same results. 

An early sign of gastric cancer is the presence of enlarged glands 
in the skin of the navel (Maunder). To ascertain the mobility and 
outline of the stomach, the patient may be desired to drink one or 
two tumblers of soda water. This distends the stomach and makes 
the tumor more prominent. 

INDIGESTION OR DYSPEPSIA. 
The symptoms of indigestion are tabulated by Dr. Murchison as 
follows* : 

1. A feeling of weight and fullness at the epigastrium and in the 
region of the liver. 

2. Flatulent distension of the stomach and bowels. 

3. Heartburn and acid eructations. 

4. A feeling of oppression, and often of weariness and aching pains 
in the limbs, or of insurmountable sleepiness after meals. 

5. A furred tongue, which is often indented at the edges, and a 
clammy, bitter, metallic taste in the mouth, especially in the morning. 

6. Appetite often good ; at other times anorexia and nausea. 

7. An excessive secretion of viscid mucus in the fauces, and at the 
back of the nose. 

8. Constipation, the motions being scybalous, sometimes too dark, 
at others too light, or even clay colored. Occasionally attacks of 

* Functional Derangements of the Liver. London, 1874. 



DISEASES OF THE DIGESTIVE SYSTEM. 1 77 

diarrhoea, alternating with constipation, especially if the patient be 
intemperate in the use of alcohol. 

9. In some patients attacks of palpitation of the heart, or irregu- 
larity or intermission of the pulse. 

10. In many patients occasional attacks of frontal headache. 

11. In many, restlessness at night and bad dreams. 

12. In some, attacks of vertigo and dimness of sight, often induced 
by particular articles of diet. 

ABDOMINAL PHTHISIS. 

Abdominal phthisis (tubercular peritonitis) in its acute forms, closely 
simulates typhoid fever. There are febrile symptoms attended with 
remissions, heat and dryness of the surface, pains in the limbs, 
drowsiness and disordered secretions, and diarrhoea. It differs from 
typhoid in these particulars. 

1. The pain is diffused over the abdomen, not limited to the csecal 
region. 

2. There are no red spots. 

3. There is generally tubercular disease in other organs. 

4. The temperature has not the morning remissions of typhoid. 

OBSTRUCTION OF THE BOWELS. 

The causes of a mechanical stoppage of the bowels are principally 
the following : intussusception ; impaction of faeces ; strictures ; twist- 
ing of the bowel (volvulus); herniae ; pressure of tumors. 

The symptom first noticed is constipation with colicky pains, 
which do not yield to ordinary remedies ; slight distension of the 
abdomen and some soreness on pressure. Vomiting follows, very 
severe, even becoming faecal. It is liable to be confounded with 
peritonitis and strangulated hernia. The following rules for diagno- 
sis have been laid down by the eminent surgeon, Mr. Jonathan 
Hutchinson, of London : 

1. When a child becomes suddenly the subject of symptoms of 
bowel obstruction, it is probably either intussusception or peritonitis. 

2. When an elderly person is the patient, the diagnosis will gener- 

12 



I 78 DIFFERENTIAL DIAGNOSIS. 

ally rest between impaction of intestinal contents and malignant dis- 
ease (stricture or tumor). 

3. In middle age the cause of obstruction may be various ; but 
intussusception and malignant disease, both of them common at the 
extremes, are now very unusual. 

4. Intussusception cases may be known by the frequent straining, 
the passage of blood and mucus, the incompleteness of the constipa- 
tion, and the discovery of a sausage-like tumor, either by examina- 
tion per anum or through the abdominal walls. 

5. In intussusception, the parietes usually remain lax, and, there 
being but little tympanites, it is almost always possible, without 
much difficulty, to discover the lump (or sausage-like tumor) by 
manipulation under ether. 

6. Malignant stricture may be suspected when, in an old person, 
continued abdominal uneasiness and repeated attacks of temporary 
constipation have preceded the illness. It is to be noted also that 
the constipation is often not complete. 

7. If a tumor be present and pressing on the bowel, it ought to be 
.discoverable by palpation, under ether, through the abdominal walls, 

or by examination by the anus or vagina, great care being taken not 
to be misled by scybalous masses. 

8. If repeated attacks of dangerous obstruction have occurred with 
long intervals of perfect health, it may be suspected that the patient 
is the subject of a congenital diverticulum, or has bands of adhesion, 
or that some part of the intestine is pouched and liable to twist. 

9. If, in the early part of a case, the abdomen become distended 
and hard, it is almost certain that there is peritonitis. 

10. If the intestines continue to roll about visibly, it is almost cer- 
tain that there is no peritonitis. This symptom occurs chiefly in 
emaciated subjects, with obstruction in the colon of long duration. 

11. The tendency to vomit will usually be relative with three con- 
ditions and proportionate to them. These are (1) the nearness of the 
impediment to the stomach, (2) the tightness of the constriction, and 
(3) the persistence or otherwise with which food and medicine have 
been given by the mouth. 



DISEASES OF THE DIGESTIVE SYSTEM. 



179 



12. In cases of obstruction in the colon or rectum, sickness is often 
wholly absent. 

13. Violent retching and bile-vomiting are often more troublesome 
in cases of gall-stones or renal calculus simulating obstruction than 
in true conditions of the latter. 

14. Faecal vomiting can occur only when the obstruction is moder- 
ately low down. If it happen early in the case, it is a most serious 
symptom, as implying tightness of constriction. 

15. The introduction of the hand into the rectum as recommended 
by Simon, of Heidelberg, may often furnish useful information. 

INFLAMMATORY DIARRHCEA (ENTERITIS) AND DYS- 
ENTERY (COLITIS). 

These diseases, both alike in being inflammations of the mucous 
membrane of the intestinal tract, are frequently associated. But for 
therapeutic as well as prognostic purposes, it is desirable to recognize 
the distinctions which they present in well marked types. They are: 



ENTERITIS. 

Seat of inflammation is in the small 
intestine. 

Usually begins with colic, nausea 
and vomiting, constipation (rarely 
diarrhoea), chilliness, soon followed by 
high fever, thirst and hot skin. 

Pulse at first tense and full ; soon 
becomes small, wiry, quick. 

Pain paroxysmal, local tenderness 
marked, greatly increased by pres- 
sure. 

Stools mucous, rarely blood, very 
rarely pus. No scybala. No tenes- 
mus. 

Aortic pulsation felt by the patient 
on the right of the umbilicus. 



DYSENTERY. 

Seat of inflammation is in the large 
intestine. 

Usually begins with painless slight 
diarrhoea, followed by chill, slight or 
no fever, sense of weight near the 
anus. No colic. 



Pulse often little excited 
fever is high, full and rapid. 



or if 



Pain more moderate, usually dis- 
tinctly over the colon, moderate ten- 
derness. 

Stools scanty, bloody, contain pus, 
scybala, little fseces. Marked tenes- 
mus. 

Aortic pulsation not noticed by the 
patient. 



l80 DIFFERENTIAL DIAGNOSIS. 

DISEASES OF THE LIVER. 

Previous to an examination of the liver, the patient should have a 
free action of the bowels, as faecal accumulations are a constant cause 
of diagnostic errors. He should lie on his back on a firm bed, with 
his knees drawn up and the abdominal muscles relaxed. Palpation 
should be upon the skin directly, not on the clothing. The physician 
seating himself on the patient's right side, should apply the tips of the 
fingers of the right hand just below the free border of the ribs, and 
request the patient to make full inspiration and expiration. He will 
thus be able to feel the upper edge and surface of the liver and ascer- 
tain the condition of its surface, whether smooth or nodular. By per- 
cussion, which should be made while the patient is in the same posi- 
tion, the size of the liver can be quite accurately mapped out. These 
two facts are the first steps to a diagnosis ; as most hepatic diseases 
can be assigned to one of these classes, 

1. Liver enlarged, with smooth surface. 

2. Liver enlarged, with nodular surface. 

3. Liver atrophied. 

Pain in the hepatic region should be examined ; whether dull or 
acute, persistent or intermittent, etc. The condition of jaundice is 
ascertained, in light cases, by examining the under surface of the 
tongue and the conjunctiva of the eye, which will display the icteric 
discoloration when the general surface does not. A still more delicate 
test of the presence of jaundice is derivable from examination of the 
urine. The following three tests are employed by Prof. Hardy, of 
Paris : 

1. Chloroform : When this is poured upon normal urine it sinks by 
reason of its great density to the bottom of the test-glass, exhibiting 
there a crystalline transparency. If we pour it on the icteric urine, 
and, having shaken the test-tube plugged by the thumb, leave it quiet 
for a moment, the chloroform deposit contrasts strongly by its dull 
color with the yellow of the superficial layers — the yellow color being 
deeper in proportion to the quantity of bile in the urine. It is an ex- 
cellent test of icteric urine. 

2. Iodine: When the iodine is poured upon the icteric urine the 



DISEASES OF THE DIGESTIVE SYSTEM. 



18 



mixture must not be shaken. At the upper part of the tube three 
very distinct colors are observable — the first layer formed by the tinc- 
ture is violet : below this is a kind of diaphragm of sea-green color ; 
and the third layer, consisting of the urine, and occupying the lowest 
part, is yellow. 

3. Nitric Acid : When this agent has been poured in, the mixture 
after shaking assumes a bottle-green color, passing into an olive. 
This is an entirely special and very characteristic appearance.* 

With these hepatic symptoms determined, a study of the following 
tables will in most instances readily supply a correct diagnosis : 

THE SIGNIFICANCE OF PAIN IN THE LIVER. 

Pain having its source in the liver is divided by Dr. Charles 
MuRCHisoNf into three varieties, each of diagnostic significance. 

CHARACTER OF PAIN. j DISEASES FOUND IN. 

I. Pain severe, paroxysmal, with ' Obstruction of the bile duct by 
distinct intermissions; little or no \ gall-stones, etc; hepatic colic ; hepat- 
local tenderness ; no fever ; often j ic neuralgia (when jaundice is absent 
associated with jaundice. probably the latter). 



II. Pain moderate, continuous, 
slightly increased by pressure, often 
associated with pain in the right 
shoulder, slight febrile symptoms and 
jaundice. 

III. Pain severe, constant, greatly 
increased by pressure, motion, cough- 
ing, etc. More or less fever ; per- 
haps jaundice. 



Congestion and commencing in- 
flammation of the organ ; catarrh 
and partial obstruction of the bile 
ducts; acute atrophy. 



Always indicates inflammation of 
the capsule (perihepatitis), which 
may supervene in various diseases 
(cirrhosis, hydatids, etc.). 



Hepatic pain may be simulated by various other conditions. The 
principal ones, with their characteristic differences, are as follows : 

1. Pleurodynia. — The pain is strictly localized to a small spot. 
Absence of hepatic disturbance. 

2. Intercostal Neuralgia. — Chiefly referred to three points in the 
course of the nerve: (1) The vertebral groove; (2) The axillary 

* Revue de Therapenlique, Aug., 1878. 
^Lectiwes on Diseases of the Liver. 



182 



DIFFERENTIAL DIAGNOSIS. 



region ; (3) The termination of the nerve in front. Co-existence of 
neuralgia elsewhere. Absence of hepatic symptoms. 

3. Pleurisy. — Presence of pyrexia and physical signs of the disease. 

4. Gastrodynia — Comes on with relation to food (stomach always 
either full or empty). Pyrosis. 

5. Intestinal Colic. — Pain referred to the umbilical region. No 
jaundice. Blue line of lead poisoning. Errors of diet. 

6. Renal Colic. — Pain chiefly referred to one kidney, when it shoots 
to the testicle and down the thigh. No jaundice. Hsematuria and 
renal calculus. 

Little or no hepatic pain is felt in 

1. The waxy, lardaceous, or amyloid liver. 

2. The fatty liver. 

3. Simple hepatic hypertrophy. 

4. Hydatid tumor. 

THE SIGNIFICANCE OF JAUNDICE. 
The common and obvious symptom of jaundice results either (1) 
from obstructions of the common bile duct; or (2) independent of 
any obstruction of the duct. The diagnosis of these two conditions 
may be presented as follows: 



JAUNDICE FROM OBSTRUC- 
TION. 

When persistent, speedily becomes 
intense. 

The stools are clay-colored. 

Tumor in the region of the gall 
bladder often present. 

May appear suddenly in a person 
in good health. 

Intermittent jaundice in advanced 
life signifies gall-stones. 

Pain, usually, in severe paroxysms. 

Co-existence of ascites, pregnancy, 
pyloric cancer (obstruction from 
without). 



JAUNDICE WITHOUT OB- 
STRUCTION. 
Persists and continues slight. 

The stools are natural. 
No tumor there. 



Appears gradually, unless there is 
a history of shock. 

Intermittent jaundice in youth sig- 
nifies catarrh of the duodenum. 

Pain usually more or less constant. 

Preceding severe mental emotion, 
pyaemia, malarial fevers, phosphorus 
poisoning, epidemic prevalence. 



DISEASES OF THE DIGESTIVE SYSTEM. 



33 



The principal diseases which are associated with these varieties ot 
jaundice are the following: 

DISEASES EXHIBITING JAUNDICE FROM OBSTRUCTION. 



Disease. 



1. Gall Stones. » 



2. Hydatids. 



3. Cancer and Tumors. 



Diagnosis. 



Biliary colic present. Pain acute, paroxys- 
mal, referred to the gall bladder, and from this 
round to the right scapula. Tenderness absent 
or slight. Irregular rigors. No fever. Severe 
vomiting. Jaundice appears after a day or two. 

; Pathognomonic ; the presence of gall stones in 

' the faeces. 

Liver enlarged and altered in form but pain- 
j less. Biliary colic with fever, quick pulse and 
j high temperature. Pathognomonic; hydatid 
vesicles in the faeces. 

Antecedent history of visceral cancerous dis- 
use Pain and nausea after taking food. A 
hard and sensitive tumor in the abdomen. 
Hemorrhage from the stomach or bowels. 



DISEASES EXHIBITING JAUNDICE WITHOUT OB- 
STRUCTION. 



Disease. 



Diagnosis. 



Malarial Fevers. 
Yellow Fever, Pyaemia 

Epidemic Jaundice. 



3. Nervous Jaundice. 



Jaundice from 

TION. 



History of malarial or specific poisoning, or 
actual presence of one of the diseases named. 

Gastric catarrh; stools pale; epigastric sore- 
ness ; nausea or vomiting ; loss of appetite ; 
often commences with a chill after exposure. 
Most epidemics of jaundice seem to have been 
due to malarious poison or vitiated atmosphere. 
Infantile jaundice is of the latter character. 

History of severe mental emotion, great suf- 
fering or sudden shock. Onset rapid ; often 
cerebral symptoms 

Conges-' Feeling of weight and soreness over liver. 
Bad breath ; poor appetite ; furred tongue ; 
vertigo Right decubitus. Urine scanty and 
high colored Slight dyspnoea. Bowels slug- 
gish 



1 84 



DIFFERENTIAL DIAGNOSIS. 



Acute atrophy, mineral poisons, especially by phosphorus, and 
very obstinate constipation, are other occasional causes of this form 
of jaundice. 

CLASSIFICATION OF HEPATIC DISEASES WITH 
REGARD TO THE SIZE OF THE LJVER* 

i. LIVER ENLARGED, SURFACE SMOOTH. 



Simple Hyperplasia. 



Leukemic Hyperplasia. 



Congestion. 
(a) Simple. 



(&) From cardiac disease. 



(/) From malaria. 



Waxy Degeneration. 



Fatty Degeneration. 



Liver enlarged, smooth, painless ; absence 
of other symptoms. 

Liver enlarged and smooth. Spleen enlarged. 
Pallor of the skin. Pathognomonic ; presence 
of a marked increase of the white blood glo- 
bules, 1:20 and upwards. 

Enlargement moderate Tenderness; con- 
junctiva jaundiced ; stools pale ; bowels irregu- 
lar ; tongue coated ; low spirits ; headache ; 
; vertigo; noises in the ears. No jaundice or 
dropsy. 

Liver enlarged, smooth. Slight jaundice. 
Some dyspnoea. Dropsical effusions. Mitral 
or aortic disease. Emphysema or induration 
of the lungs. 

Enlargement slight. Enlarged spleen. His- 
tory of malarial disease. Pathognomonic : the 
malarial pigment in the blood. 

Enlargement considerable, uniform, of slow 
growth, borders sharply defined, feel firm. Pain 
slight. Patient emaciated and cachectic. Splenic 
enlargement common. Diarrhoea and dyspep- 
sia. History of phthisis, syphilis or protracted 
suppuration. 

Enlargement considerable, borders rounded, 
feel doughy. No tenderness nor pain. Spleen 
small ; jaundice slight or absent. Diarrhoea. 
A pale, smooth, greasy skin. History of intem- 
perance, phthisis or indolent life. 



* Partly taken from E.J. Janeway, Diagnosis of Hepatic Affections. N. Y., 1 877. 



DISEASES OF THE DIGESTIVE SYSTEM. 



Hydatid Tumors. 



Simple Atrophy. 



Acute Yellow Atrophy 



Enlargement considerable, irregular, pain- 
\ less ; usually of left lobe of the organ. Feel 
I elastic or fluctuating. Jaundice rare. Increase 
! of size slow. No constitutional symptoms. 

Liver small, surface even. Preceded by 
I. ascites, dyspnoea, serious disease of heart or 
I lungs, or signs of congestion. 

Rare. Jaundice always present, though 
i rarely intense. Pain considerable. Tenderness. 

Generally vomiting; splenic dullness. Pulse ir- 
! regular. The typhoid state common. Urine 
I dark, acid, sp. grav. 1012-1024; absence of 

urea, uric acid, and the chlorides ; presence of 
! leucine and tyrosine (pathognomonic). Intes- 
1 tinal hemorrhage and hsematemesis common. 



II. LIVER ENLARGED, SURFACE NODULAR OR IRREGULAR. 

Abscess or Tropical Hep-' Liver enlarged, irregular surface bulging. 
atitis. Dull heavy pain. Jaundice rare. Pyrexia and 

chills. History of residence in a warm cli- 
mate. 



Cancer. 



Syphilitic Liver. 



Enlargement often very great, progressive, 
irregular ; nodular excrescences often to be 
felt. Feel hard and resistant. Pain lancinat- 
j ing and tenderness acute. No febrile symp- 
toms. Jaundice. "The co-existence of en- 
• larged liver with persistent jaundice ought 
' always to raise the suspicion of cancer" 
I (Murchisonj. Dyspepsia, nausea, vomiting, 
1 constipation or diarrhoea, short, dry cough, 
ascites. Patients over 40. In suspected can- 
cer of the liver the urine should always be ex- 
amined ; half a drachm of strong nitric acid 
I should be added to half an ounce of the urine. 
If the fluid changes to a dark or black hue, 
i and especially if no albumen is present, and 
the liver is either increased or diminished in 
size, the diagnosis of melanotic cancer is ren- 
dered very probable. (Dr. Eiselt, of Prague.) 

Liver enlarged, surface nodulated, lobes ir- 
regular, separated by deep fissures. 



I 86 DIFFERENTIAL DIAGNOSIS- 

III. LIVER DIMINISHED IN SIZE. 



Cirrhosis, or Chronic 
Atrohy. 



Liver small, sometimes only half size, sur- 
face granular or nodulated; " hob-nail liver." 
j Outset insidious, with signs of disorded diges- 
tion. Dull pain and slight tenderness in he- 
patic region. Ascites common. Spleen often 
enlarged. Superficial veins of the abdomen 
enlarged. Hemorrhoids frequent. Jaundice 
rare or slight. Progressive emaciation and de- 
bility. History of spirit drinking almost in- 
variably. 



HEPATIC ABSCESS. 

It has lately been shown* that an obscure and chronic form of 
hepatic abscess is a far more common disease in the United States 
than is generally supposed, and that it is often exceedingly difficult 
of diagnosis. 

These abscesses may exist without any local symptoms or such 
general disturbance of the system as is commonly regarded as indi- 
cating their presence, and are a very common concomitant of pro- 
longed malarial poisoning. The pathognomonic sign of their presence 
is the discovery of pus on aspiration of the parenchyma of the liver. 
This operation is not dangerous, and there need be no hesitation in 
its performance. The place of election is one of the intercostal 
spaces. The rational symptoms may be collated as follows: 

1. Gastric and intestinal derangements ; dyspeptic symptoms of 
various kinds. 

2. Slight jaundice ; conjunctivae yellow ; complexion sallow. 

3. Depression of spirits, hypochondria or melancholy. This is a 
very usual symptom, and so important that Dr. Hammond recom- 
mends that in all cases of hypochondria or melancholia, the region 
of the liver should be carefully explored, and even if no fluctuation 
be detected or any other sign of abscess be discovered, aspiration, 
with proper precautions, should be performed. If pus be evacuated, 
the operation may be expected to be followed by a cure of the 

*Tauscky, Med. Record, April 20, 1878; Hammond, St. Louis Clin. Record, June, 
1878; Byrd, N."V. Med. Journal, July, 1878, etc. 



DISEASES OF THE DIGESTIVE SYSTEM. 1 87 

mental disorder, as well as by the preservation of the life of the pa- 
tient from the probably fatal consequences of hepatic abscess. 

4. Sense of weight or pain in the right side; more or less tender- 
ness on pressure (all local symptoms often absent). 

5. Circumscribed fluctuation over the hepatic region. This is a 
positive sign, but is by no means always to be discovered. 

6. Cerebral symptoms, as vertigo, cephalalgia, insomnia, and hyper- 
emia. 

7. Slight rigors, and feverishness, simulating some of the more 
chronic forms of intermittent fever. 



1 88 



DIFFERENTIAL DIAGNOSIS. 



INTERNAL PARASITES. 
The symptoms to which parasites in the intestinal canal and other 
organs give rise are numerous, but by no means specific or definite. 
The following tabular arrangement sets forth the more prominent : 



Tape Worm. 



Hydatid Cysts. 



Round Worms, Lumekici. 



Thread Worms. 



Pain and discomfort in the belly ; variable 
I appetite ; constipation and diarrhoea alternat- 
ing ; itching at the nose or anus without local 
cause, low spirits, loss of flesh, nervous seiz- 
ures. Stools unusually dark or light. 

Pathognomonic : The discovery of joints in 
the stools, or about the anus, or of eggs in the 
faeces (microscopic). 

These occur chiefly in the lungs and liver. 
(See Diseases of the Liver.) They begin with 
a rounded, tense, smooth, elastic swelling, 
painless until inflammation begins, and without 
other symptoms than those caused by their size. 
They are often attended with the " hydatid 
thrill." This may be felt by placing the left 
hand flat and closely upon the tumor, then 
percussing sharply with the fingers of the right 
hand. A long sustained tremor is observed, 
"like that experienced on an iron railway 
bridge during the passage of a train." 

Pathognomonic: Echinococci or micro- 
scopic hydatids in the contained fluid, which 
may safely be drawn by aspiration. 

Symptoms of intestinal irritation. Capricious 
appetite. Pain of a gnawing or griping char- 
acter. Tenderness on deep pressure over the 
abdomen. Tumid condition of the belly. Al- 
ternate constipation and diarrhoea. The tongue 
pale, flabby, indented by the teeth, and often 
has a peculiar shiny appearance. Pupils gen- 
erally dilated. Squinting, nervous twitchings, 
or even convulsions. Sleep is restless, with 
grating of the teeth and waking with sudden 
starts. Fever may appear, often of a remittent 
type (worm fever, verminal fever). 

Violent itching and irritation at the anus and 
vagina, increased at night. Tendency to 
strain. Itching at the nose. 



DISEASES OF THE DIGESTIVE SYSTEM. 



189 



Trichinae Trichinosis. 



I First Stage 



Gastro-intestinal disturbances 
thirst ; loss of appetite ; nausea; colicky pain ; 
! in the abdomen ; constipation or diarrhoea ; 
i coated tongue ; feverishness. Second Stage: 
I Swelling and stiffness of the muscles ; muscular 
soreness ; oedema of the subcutaneous tissue ; 
copious sweating ; debility and increased fever ; 
dyspnoea, hoarseness and loss of voice ; dropsy 
commencing in the eyelids and face, and pro- 
ceeding to the extremities ; difficulty of motion 
and respiration. 

Pathognomonic: Presence of trichinae in the 
faeces, or in the muscular structure. 

The differential diagnosis from rheumatism 
is in the soreness being in the muscles and not 
the joints ; from typhoid fever in the unusual 
pain and stiffness ; the early swelling, dropsy, 
etc. 

Trichinae do not colonize equally throughout 
a muscle, but in groups here and there. It is 
best, therefore, to dissect out a muscle length- 
wise in order to judge of their number. 



The very large number of symptoms attributed to the presence of 
worms in the intestinal canal is the irritation they cause, implicating 
the general nervous system. This, occasionally, extends so far as to 
produce a "worm fever," which in many respects resembles a mild 
remittent with unusually pronounced nervous symptoms. The 
tongue is pale and flabby, and often has a peculiar shiny appearance 
(Date). The pupils are generally dilated. Squinting sometimes 
occurs, and nervous twitchings of a choreic character. The fever is 
often high, with great heat of skin, and the cerebral manifestations 
being marked, may lead to the suspicion of hydrocephalus. From 
this it can be distinguished by the mere direct remissions; by the 
previous history, showing the primary symptoms to be referable to 
derangements of the elementary canal; by the less obstinate constipa- 
tion ; and by the expulsion of worms. 



I9O DIFFERENTIAL DIAGNOSIS. 

It has also been confounded with tubercular disease. Here the 
most important diagnostic point is the temperature. This in tuber- 
cular disease is always high ; but when the irritation is from worms 
it is either normal or but temporarily elevated above the normal 
standard. 



CHAPTER V. 

DISEASES OF THE URINARY SYSTEM. 

The Early Signs of Bright 's Disease. Comparative Diagnosis of the 
Different Forms of Bright' s Disease [Acute Parenchymatous Nephri- 
tis, Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Con- 
traction of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albu- 
minoid or Angloid Renal Degeneration, Parenchymatous Renal De- 
generatioii). Diabetes Mellitus and Glycosuria. Diabetes Insipidus 
and Hydruria, Urinary Calculi. 

General methods for the examination of the urine, and the chem- 
ical reagents and manipulations required in its analysis, are to be 
found in so many text-books and treatises that we may omit them 
here, and confine ourselves to the differential symptoms of some ot 
the most prominent and frequent renal diseases. 

THE EARLY SIGNS OF BRIGHT'S DISEASE. 

The early progress of Bright's disease is often remarkably insid- 
ious, and readily escapes recognition. Nor is it to be detected by the 
familiar and easy plan of testing for albumen. This substance is by 
no means invariably present in the urine, even in advanced and well- 
marked cases. Fothergill justly observes that the progress of in- 
terstitial nephritis is often without the albuminous secretion for long 
periods. 

On the other hand, it has been abundantly shown that albumen is 
occasionally and transiently present in the urine of persons who pre- 
sent no traces of nephritis; who, in fact, may be in excellent health. 

Hence the value of other means of determining the existence of 

(191) 



I92 DIFFERENTIAL DIAGNOSIS. 

these forms of renal disease becomes manifest. Of these the pres- 
ence of hyaline casts has recently been urged as pathognomonic of 
renal hyperemia and inflammation, and invariably present* These 
must be sought for with considerable care, as from their transparent 
character, and the fact that they do not form a sediment, they are 
readily overlooked. The directions given for their search are that 
the urine to be examined is placed in a tall conical glass ; after 
three to six hours it is inspected ; from the visible deposits, 
whether floating or sedimentary, with the pipette a quantity is 
taken sufficient to fill a concave slide or a shallow cell. 

This little pool is first searched with a four-tenths objective, and in 
a little time any cast or other miscroscopic object it contains is found. 
A more careful observation is made of the object thus found with the 
one-fifth. When the examination of deposits has been made in this 
way, the conical glass of urine should be set aside (a little chloral 
may be added to prevent decomposition), and after twelve hours more 
the examination should be repeated. Of course it will be remem- 
bered that the hyaline cast may be found when the condition of the 
kidney is only one of transient hyperemia. 

The effort has also been made to call in the aid of the ophthalmo- 
scope. The presence of minute white exudations -in the retina, princi- 
pally around the maculae luteae, are believed to point to the presence 
of Bright's disease, and to be found in its early stages. The appear- 
ance of the retina in .these cases is characteristic. It consists in the 
grouping of small white spots, the outline of each being clearly 
defined ; they are invariably circular, of extremely small dimensions, 
and present the appearances of a pearl of an intensely bright color, 
and stand out from the retina in a marked manner. The grouping of 
the spots is symmetrical in each eye, and is generally in the form of 
a crescent. Often the urine will only yield signs of the minutest 
quantities of albumen — sometimes none at all ; but hyaline casts and 
these white spots may be detected by the processes here described. 

In the form of amyloid degeneration the difficulties of diagnosis are 
yet increased, as not only has it been generally recognized that albu- 

*Dr. B. A. SEGUR, Proceedings of the Medical Society of Kings Co., 1878, p. 241. 



DISEASES OF THE URINARY SYSTEM. 1 93 

men may be absent for considerable periods while the disease is 
steadily advancing, but it has been abundantly shown that it may 
never appear at all in fatal cases." 

It seems, therefore, certain that we possess at present no sure 
diagnostic of amyloid degeneration of the renal vessels ; that on the 
one hand, it is likely to be confounded with, or mistaken for, chronic 
parenchymatous nephritis arising under identical etiological condi- 
ditions ; on the other, it runs a great risk of being altogether over- 
looked. But both of these evils may be avoided with a little care. 
Bartels points out that the differential diagnosis between amyloid 
disease and chronic parenchymatous nephritis depends upon the dis- 
tinguishing characters of the urine, which, in the former, is clear with 
little sediment and few casts, mostly hyaline, and scarcely ever blood- 
corpuscles ; in the latter it is always more or less turbid, with consid- 
erable sediment, is dirty colored, contains many casts of every variety, 
and not uncommonly blood-corpuscles. In those cases in which no 
albumen was present, there have been signs of amyloid disease in 
other organs ; and, in order to escape error, it will be enough to 
know that the absence of albumen from the urine does not exclude a 
slight degree of amyloid disease of the kidneys. 

We shall now proceed to classify the diagnostic points in the 
differentiation of the seven forms into which the varieties of Bright's 
disease are now divided. 

*Lecorche, Maladies des Reins, Paris, 1875; Litten, Berlhier Klinische Wochenschrift, 
June, 1878. 

13 



194 



DIFFERENTIAL DIAGNOSIS. 



COMPARISON OF THE DIFFERENT 



History. 



Appearance. 



Urine. 



Prognosis. 



Pathology. 



Acute Parenchymatous 
Nephritis. 



Sfldden onset after scar- 
let fever or exposure 
to wet and cold. 
(Edema of the face 
the sign first noticed ; 
headache, feverish- 
ness, pain in the 
loins, gastric disturb- 
ance. 

Dropsical, swollen 
about the face ; skin 
generally dry. 



Scanty, smoke-colored, 
dark when acid, red 
if alkalized. Highly 
albuminous. Specific 
gravity high, 1025- 
1030. Reddish 
brown sediment of 
epithelial, blood and 
hyaline casts. 

Recovery frequent. 
May lead to chronic 
tubal nephritis. 



Kidneys enlarged, con 
gested, vascular ; cor- 
tical substance in 
creased. Tubules 

dark and dense. 



Chronic Tubal 
Nephritis. 



Symptoms of more than 
six weeks' duration. 
Often history of acute 
nephritis. Uraemic 
symptoms ; abnor- 
mally low tempera- 
ture. Serous in- 
flammations. Car- 
diac hypertrophy. 

More or less oedema, 
and general anasarca. 
A pale, almost char- 
acteristic, waxy look. 



Generally scanty, 
though variable. 
Pale, albumen about 
one-fourth, specific 
gravity low, 1005- 
1015; white sedi- 
ment of hyaline and 
epithelial casts. No 
blood casts. 

Recovery not likely. 



Kidneys enlarged, cor 
tical substance in- 
creased, capsules eas 
ily separated. 



Yellow Fatty Kidney 



Often follows alcohol- 
ism. 



Dropsy considerable 
and persistent ; renal 
cachexi a often 
marked. 



Scanty, pale, low spe- 
cific gravity, with 
abundant sediment of 
oil casts and cells 
filled with oil. Al- 
bumen abundant. 



Almost certainly fatal. 



Kidneys enlarged, fatty, 
mottled, the tubes 
full of fat and oil 

cells. 



DISEASES OF THE URINARY SYSTEM. 



195 



FORMS OF BRIGHT'S DISEASE. 



Secondary Contraction 
of Kidney. 



In te rstitial Neph ritis . 
Renal Cirrhosis. 



Symptoms of more than 
a year's duration. 
Headache. Coma or 
convulsions. Car- 

diac hypertrophy. 
Epistaxis. 



Generally some dropsy, 
but not very exten- 
sive. Face sallow. 



Scanty, pale, specific 
gravity about 1015. 
Albumen moderate. 
Sediment of pale, 
casts, dark granules,' 
fatty cells and waxy| 
products. 



Generally fatal, but of 
slow progress. 



Kidneys contracted, 
dense, capsule adher- 
ent; atrophy of the 
tubules. 



Symptoms few and 
faint. Often the ar- 
t h r i t i c diathesis. 
Exposure to cold 
and fatigue. Sense 
of weariness. Fre- 
q u e n t headaches. 
Amaurosis. Cardiac 
hypertrophy. 

Little or no dropsy. 
Nerve implications, 
as paralysis, loss of 
sight or hearing, etc. 



Largely increased, pale; 
albumen trifling; sed- 
iment little, of finely 
granular casts, or 
minute oil drops. 
Specific gravity low. 



With care, not imme- 
diately dangerous, but 
predisposes to urae- 
mic attacks from ex- 
posure. 

Kidneys at first en- 
larged, later con- 
tracted ; connective 
tissue increased ; cap- 
sule adherent, dimin- 
ished and corrugated. 
" Chronically con- 
tracted" kidney. 



Albuminoid or Amyloid 
1 Renal Degeneration 



Antecedent syphilis, 
phthisis or osseous 
disease. Enlarged 
liver or spleen. 
Chronic diarrhoea. 



Dropsy, 

amenable to treat 
ment. Emaciation 
Face sallow or pallid 
Dyspnoea. 



Parenchymatous 

Renal 
Degeneration. 



Pregnancy, diph- 
theria, or acute 
fever. 



generally G e n e r a lly no 
dropsy. 



Largely increased, (50- 
60 oz. ) pale or golden ; 
albumen considera- 
ble, perhaps one- 
half. Specific grav- 
ity 1007-1015; little 
or no sediment ; 
casts hyaline and 
waxy. 

Incurable, though the 
patient may live for 
years. 



Kidneys enlarged, 
smooth, waxy look- 
ing. 



N 



ormal 
amount. Al- 
bumen r \ to 4- 
bulk. 



i n 

Al- 



Recovery fre 
quent. 



Kidney enlarged, 
the paren- 
chyma more or 
less hypertro- 
phied. 



: 9 6 



DIFFERENTIAL DIAGNOSIS. 



DIABETES MELLITUS AND GLYCOSURIA. 

The presence of sugar in the urine is characteristic of both these 
conditions. The most convenient, simple test is caustic potash, 
either in solution or small fragments. Heated with urine containing 
sugar, this substance immediately produces a more or less yellow or 
brown color, the intensity of which is in proportion to the quantity of 
sugar present. 

Apart from this test, the presence of sugar in the urine is revealed 
by many indications. We may often recognize it by grayish patches 
on the clothing or linen, which are reduced to powder when scratched 
with the nail. In women the chemise, from prolonged contact with 
the urine, may become spotted and stiffened as if by drops of syrup. 
Another circumstance indicating the sugary savor of the urine, 
especially in the country, is the great number of flies or ants that will 
be attracted around the vessel containing it. 

The presence of sugar once determined, it remains to decide 
whether it arises from simple glycosuria, which is a comparatively 
common and not dangerous condition, or from saccharine diabetes, 
which is much more rare and a very perilous affection. This distinc- 
tion has lately been insisted upon by M. Gerin Rozes. The con- 
trasting features of the two disorders may be presented as follows : 



DIABETES MELLITUS. 

Onset gradual ; occurs at all ages, 
and without reference to known pre- 
disposing causes. 



The amount of sugar varies very 
little. 



The absence of saccharine food 
makes little or no change in the 
urine. 



SIMPLE GLYCOSURIA., 
Onset sudden; more common in 
the aged; in persons consuming 
saccharine food ; in the insane ; in 
those taking chloral; in the parox- 
ysms of ague ; after sudden excite- 
ment ; blows on the head ; cerebral 
affections. 

The amount of sugar varies greatly 
from day to day (pathognomonic, 
Rozes). 

The withdrawal of saccharine food 
diminishes the sugar. 






DISEASES OF THE URINARY SYSTEM. 1 97 

DIA BETES MELLITUS. SIMPLE GLYCOSURIA. 

Volumetric analysis by Fehling's Such analysis is obscure, owing to 
method is easy. the quantity of creatinine substances 

present. 

Polyuria, polyphagia, polydipsia, All these may be, and generally 
and impotence common and well are, absent, or slightly marked, 
marked. 

Nervous complications frequent. Rare. 

Treatment of little avail ; result Treatment efficient ; result usually 
usually fatal favorable. 

With the knowledge of the very fatal character of diabetes melli- 
tus, a recognition of its earliest symptoms becomes of immense im- 
portance for treatment. Its invasion is seldom sudden, and at the 
very outset it is curable, which it rarely or ever is, when once devel- 
oped. 

Various nervous symptoms are among the earliest noted, and it is 
a wise rule in all nervous disorders of a doubtful character to exam- 
ine the urine for sugar. Changes in the character of an individual, 
an abnormal irritability of temper, insomnia, and extreme feeling of 
fatigue, disorders of vision, itching of the skin, pruritus of the genital 
organs, especially the vulva, and more or less protracted headache, 
are often premonitory symptoms. Intense and obstinate neuralgic 
pains, without obvious caase, especially in the foot and leg, should 
lead to the suspicion of diabetes. Recurrent boils and carbuncles 
are well known to accompany the diabetic condition. 

Genital impotence is one of the first signs of approaching diabetes ; 
and whenever individuals are met with who, previously virile, 
become weak and impotent without coinciding disease, especially 
of the spinal marrow, diabetes will usually be found to be the cause. 
Valuable information is derivable from the mouth ; for besides the 
insatiable thirst and dry mouth, some patients complain of a disa- 
greeable taste, which is sometimes acrid, and at others faint or bitter 
or sugary; and it is this perverted taste which contributes to maintain 
the thirst. 

The mouth frequently exhibits an aphthous condition, while the 



I90 DIFFERENTIAL DIAGNOSIS. 

edges and tip, and even the whole surface of the tongue, may present 
a red aspect, as if the aphthae had been removed. The gums also are 
often softened, fungous or bleeding ; while in some the teeth become 
loose or fall out without being decayed, and in others become carious. 
The breath is frequently of a bad, acid smell, and the saliva on ex- 
amination is acid instead of neutral. Another fact which has some- 
times led to the diagnosis, is the existence of intertrigo at the com- 
missure of the lips. This intertrigo labialis is not exclusively con- 
nected with diabetes, but when met with should always lead to an 
examination of the urine. 

With regard to the digestive organs, bulimia on the one hand, and 
a complete repugnance for food on the other, with dyspepsia, should 
lead us to suspect diabetes. The unusual thirst of diabetics prompts 
them to drink at night, and such a habit should suggest strict inquiry 
for other symptoms. As a general rule it may be said that whenever 
there is muscular debility, emaciation and anaemia without discovera- 
ble local cause, the urine should be examined, and will almost always 
be found to contain either sugar or albumen. 

DIABETES INSIPIDUS AND HYDRURIA. 
The habitual discharge of an excessive amount of urine of low 
specific gravity, and containing neither albumen nor sugar, if accom- 
panied with progressive emaciation, excessive thirst, and loss of vital 
power, constitutes diabetes insipidus ; but under various conditions 
excessive diuresis may be temporarily present, as in hysteria and other 
cerebro-spinal and nervous affections, without serious general symp- 
toms, and constitute the condition of hydvuria. The distinction be- 
tween the two can be made by noting the coincident disease in the lat- 
ter form, the slight direct impairment of the general health, the varying 
amount of urine voided, and by the fact that the quantity, although 
large, never attains those extraordinary measures — thirty to fifty pints 
daily — which marked cases of diabetes insipidus present. A large 
amount of urine is discharged by patients with amyloid degeneration 
of the kidney. 



DISEASES OF THE URINARY SYSTEM. 1 99 

URINARY CALCULI. 
There are but three forms of calculi which are of at all common 
occurrence, and which are, therefore, likely to demand analysis. 
These are uric acid and compounds, oxalate of lime, and the mixed 
phosphates. Calculi of xanthine and cystine are found, though very 
rarely. 

1. Uric acid calcidi are the most common. They are either red or 
some shade of red, and usually smooth, but may be tuberculated. 
They leave a mere trace of residue after ignition. 

2. Oxalate of lime calcidi are frequently met with. They are gen- 
erally of a dark-brown or dark-gray color, and from their frequently 
tuberculated surface have been called mulberry calculi. They may, 
however, also be smooth. Considerable residue remains after igni- 
tion. The calculus is soluble in mineral acids without effervescence. 

3. Calcidi of the mixed phosphates or fusible calculi are composed of 
the phosphate of lime and of the triple phosphate of ammonia and 
magnesia. They form the external layer of many calculi of different 
composition, and may form entire calculi, but very seldom form 
the nuclei of other calculi. They are white, exceedingly brittle, fuse 
in the blowpipe flame, and are soluble in acids, but insoluble in alka- 
lies. 

Few calculi of large size are of the same composition throughout. 
Oxalate of lime is the most frequent nucleus; uric acid may also 
serve as a nucleus, but phosphates, as stated, almost never. Small 
collections of organic matter, as blood-clots, frequently form nuclei, 
and may often be recognized by the odor of ammonia on ignition. 
It is not uncommon to find calculi made up of concentric layers 
of different composition. 

TO DETERMINE THE COMPOSITION OF CALCULI*. 
Heat a portion of the powdered calculus to redness upon platinum 
foil. Note whether there is a residue. 

* The processes here given are taken, with slight alterations, from Thudichum's work on 
the Pathology of the Urine. 



200 DIFFERENTIAL DIAGNOSIS. 

A. There is a fixed residue. To a portion of the original powder ap- 
ply the murexid test. This is as follows: Dissolve a small portion 
of the powder in a drop or two of nitric acid on a porcelain plate, 
then carefully evaporate over a spirit lamp. When dry add a drop 
or two of liquor ammoniae, when if uric acid is present, a beautiful 
purple color will appear where the ammonia spreads. 

I. A purple color results; uric acid is present. Observe whether 
a portion of the calculus melts on being heated. 

a. It melts and communicates — 

1. A strong yellow color to the flame of a spirit lamp : 
sodium urate. 

2. A violet color to the flame ; potassium urate. 

b. It does not melt. Dissolve the residue after ignition in a 
little dilute HC1, add ammonia until alkaline, and then 
ammonium carbonate solution. 

1 . A white precipitate falls ; calcium urate. 

2. No precipitate. Add some hydric sodic phosphate 
solution ; a white crystalline precipitate falls ; mag- 
nesium urate. 

II. No purple color results. Observe whether a portion of the 
calculus melts on being heated strongly. 

a. It melts (fusible calculus). Treat the residue with acetic 
acid; it dissolves. Add to the solution ammonia in 
excess ; a white crystalline precipitate falls ; ammonio- 
magnesium phosphate. In case the melted residue is 
insoluble in acetic acid, treat with HC1 ; it dissolves. 
Add to the solution ammonia ; a white precipitate indi- 
cates calcium phosphate. 

b. It does not melt. " Moisten the residue with water, and 
test its reaction with litmus paper ; it is not alkaline 
Treat with HC1 ; it dissolves without effervescence. Add 
to the solution ammonia in excess ; white precipitate ; 
calcium phosphate. Treat the calculus with acetic acid; 
it does not dissolve. Treat the residue after heating with 
acetic acid ; it dissolves with effervescence ; calcium oxa- 



DISEASES OF THE URINARY SYSTEM. 201 

late. Treat the original calculus with acetic acid ; it dis- 
solves with effervescence ; calcium carbonate. 
B. There is no fixed residue. Apply the murexid test (p. 200). 

I. A purple color is developed. 

a. Mix a portion of the powdered calculus with a little 
lime, and moisten with a little water; ammonia is evolved, 

• and a red litmus paper suspended over the mass is turned 
blue ; ammonium urate. 

b. No ammonia ; uric acid. 

II. No purple color. 

a. But the nitric acid solution turns yellow as it is evapor- 
ated, and leaves a residue insoluble in potassium carbon- 
ate ; xanthine. 

b. The nitric acid solution turns dark brown, and leaves a 
residue soluble in ammonia ; cystine. 



INDEX. 



Abdominal phthisis, 177 

Abscess, Cerebral, 97. 

Acidity of the Stomach, 167. 

Ai.brecht, R., 57. 

Allen, R. G., 32. 

Anaemic murmurs, 153. 

Anaemia, Pernicious, 71. 

Anaemia, cerebral, 73, 

Angina pectoris, 155. 

Anstie, F. E., 95. 

Aortic diseases, 155. 

Apoplexy, 74. 

Apoplexy, Meningeal, of the Cord, 81. 

Apoplexy, Spinal, 81. 

Apoplexy, Pulmonary, 140. 

Arthritic dyscrasia, the, 60. 

Arthritis rheumatica deformans, 70. 

Ascarides, 188. 

Asthma, 141, 140. 

Atrophy of the Liver, 185. 

Barlow, Thos., 98. 
Bennett, J. H., 122, 151. 
Billroth, T., 59. 
Bocher, Dr., 70. 
Bowels, Obstruction of, 177. 
Bramwell, B., 72. 
Bright's disease, 191. 
Broca, Dr. 78. 
Bronchitis, 128, 132, 134. 
Browne, L., 105. 
Bullard, G, B., 38. 
Buzzard, Dr., 76. 

Calculi, Biliary, 183. 
Calculi, Urinary, 199. 
Cancer of the Lung, 145. 
Cancer of the Liver, 183, 185. 
Capillary Bronchitis, 134. 
Cardiac dilatation, 161. 
Cardiac hypertrophy, 162. 
Cardiac degeneration, 163. 
Cerebral abscess, 96. 
Cerebral congestion, 73. 
Cerebral hemorrhage, thrombosis, and 
bolism compared, 76. 



Cerebro-spinal meningitis, 47. 

Cerebro-spinal sclerosis, 85. 

Cirrhosis of liver, 186. 

Cirrhosis of kidney, 195. 

Clubbing of fingers, 152. 

Charcot, Prof., 76, 99. 

Cheyne-Stokes respiration, 163. 

Colitis, 179. 

Congestive pernicious malarial fever, 48. 

Conrad, j. S., 27. 

Consumption, Galloping, 130. 

Continued fever, 37. 

Copland, Dr., 36. 

Cord, Diseases of the, 76. 

Cord, Congestion of, 81. 

Croup, no. 

CURTMAN, C. O., 45. 

Da Costa, J. M., 25, 33, 50, 55. 
Dartrous dyscrasia, the, 60. 
Degeneration, Fatty, of heart, 162. 
Delafield, F., 62. 
Diabetes, 187, 198. 
Diarrhoea, 179. 
Diphtheria, 1 10. 
Dobell, H., 152. 

DONNET, J. J. L., 55. 

Dowell, G., 53, 55. 
Dowse, Dr., 49. 
Drachmann, Dr., 70. 
Drake, D, 40, 43. 

DUCHENNE, Dr., 93. 
DUGGAN, J., 26. 
Dyscrasiae, the ,59. 
Dysentery, 179. 
Dyspepsia, 173. 

Eichhorst, Dr., 71. 
Embolism, cerebral, 75. 
Emphysema, 143. 
Empyema, 137. 
Endocardial sounds, 160. 
Enteritis, 179. 
Entero-miasmatic fever, 38. 
Epilepsy, 99. 
Eructation, 169. 

( 2 03) 



204 



INDEX. 



Eruptive fevers, 25. 
Essential fever, 23. 
Exanthemata, the, 25. 

Fatty degeneration of heart, 162. 
Fatty degeneration of liver, 184. 
Fatty degeneration of kidney, 194. 
Febrile state, the, [9. 
Fingers, clubbing of, 152. 
Flatulence, 169. 
Flint, A., 75. 

Gallstones, 183. 
Garrod, A. B., 70. 
Gastric fever, 36, 37. 
Gastric ulcer, 174. 
Gastric cancer, 174. 
Gelpke, Dr., 75. 
General diseases defined, 17. 
Glycosuria, 196. 
Gout, 69. 

Gout, Rheumatic, 70. 
Gowers, Dr., 71. 
Griffin, W. and D., 97. 

Habershon, S. O., 65. 
Hall, J. C., 46. 
Hamilton, A. M., 48, 52, 73. 
Hardy, Dr., 60. 
Heart, pain in, 153. 
Hemorrhage, cerebral, 75. 
Hemorrhagic malarial fever, 44. 
Hepatic disease, 184. 
Hepatic abscess, 186. 
Hewitt, P., 60. 
Hayden, Dr., 49. 
Howard, Henry, 102. 
Hume, E. M., 38. 
Hutchinson, John, 61, 63. 
Hydruria, 198. 
Hydatids in the liver, 183. 
Hyperplasia of the liver, 184. 
Hypertrophy of the heart, 162. 
Hysteria, 98. 

Indigestion, 176. 
Inflammatory fever, 23. 
Inflammatory diarrhoea, 179. 
Intercostal neuralgia, 1 81. 
Intussusception, 177. 
Insanity, 101. 

Jaundice, 182. 

JURGENSEN, Dr., ^. 



Kelsh, A., 47. 

Kidney, Diseases of, 191. 

Larrabee, A., 33. 

Laryngitis, 105. 

Larynx, Diseases of, 104. 

Lead Poisoning,. Paralysis from, 94. 

Leukemia, 71. 

Liver, Diseases of, 180. 

Local diseases defined, 17. 

Locomotor ataxia, 76, 83, 85 ; compared 

with general paralysis, 91. 
Love, Wm., A., 45. 
Lumbrici, 188. 

Mac Swiney, Dr., 132. 

Malarial fever, 38, 43, 48. 

Malignant remittent, 44, 48. 

Mania, 101. 

Measles, 25. 

Melancholia, 101. 

Meningeal Apoplexy, 81. 

Meningitis, cerebro-spinal or epidemic, 47, 

Meningitis, sporadic or basic, 49. 

Meningitis, acute tubercular or granular, 52. 

Miliary Tuberculosis, 180. 

Mitchell, S. W., ioi. 

Mitral, diseases, 157. 

Monti, Alois, 25. 

Multilocular sclerosis, 76. 

Myalgia, 95. 

Myelitis, acute primary, 82. 

Myelitis, chronic, 82, 84. 

Nephritis, 194. 

Nervous fever, ^J. 

Neuralgia, 94; compared with myalgia, 95 ; 

of the head, 97. 
Niemeyer, F. Von, 37. 
Noel, L. G., 68. 
Norton, A. T., 112. 

Obstruction of the Bowels, 177. 
Osler, Dr., 27. 

Paget, Sir J., 60. 
( Pain at the heart, 153. 
Pain in the stomach, 169. 
Pain in the liver, 181. 
Paralysis agitans, 85 ; General, 76, 88 ; 

compared with locomotor ataxy, 91; with 

syphilitic paralysis, 92. 
Paralysis, the forms of, 79. 
Paralysis, syphilitic, 192. 



INDEX. 



205 



Paralysis, pseudo hypertrophic, 93. 
Paralysis from lead poisoning, 94. 
Paraplegia, 79. 
Paraplegia reflex, compared with that from 

myelitis, 86. 
Parasites, Internal, 188. 
Payne, A. S., 27. 
Pericarditis, 159. 
Pericarditis with effusion, 161. 
Perichondritis, 108. 
Pernicious anaemia, 71. 
Phthisis, 123, 129. 
Phthisis, Abdominal, 177. 
Pleurisy, 135, 137. 
Pleurodynia, 1 81. 
Pneumonia, 135. 
Pneumothorax, 141. 
Pneumo-hydro-thorax, 142. 
Poisoning, narcotic, ursemic, 74. 
Progressive locomotor ataxia, see Sclerosis, 

posterior spinal. 
Pseudo-hypertrophic paralysis, 93. 
Pulmonary apoplexy, 140. 
Pulmonary cancer, 145. 
Pulmonary obstruction, 158. 

Relapsing fever, 57. 

Remittent fevers, 44. 

Remitto-typhus fever, 38. 

Renal disease, 66, 68, 191. 

Renal colic, 182. 

Reynolds, R., 61. 

Rheumatic gout, 70. 

Rheumatism, 65; compared with gout, 69. 

Rheumatism, Chronic, 66. 

Rheumic dyscrasia, the, 60. 

Richardson, J. G., 71. 

Ringer, S , 20, 23. 

Rosenthal, Dr., 80. 

Rubeola, 25. 

Scarlet fever, 25. 

Sclerosis, posterior spinal, 67, 76, 8^, 85, 91. 

Sclerosis, multilocular, 76. 

Sclerosis of antero-lateral column, 83. 

Scrofulous dyscrasia, the, 61. 

Seguin, E. C, 91, 101. 

Small-pox, 25. 

Smith, A. H, 114. 

South ey, R., 52. 

Spinal apoplexy, 81. 

Spinal tumors, 82. 

Spinal irritation, 96, 97. 

Spotted fever, 47. 

Squarey, Dr., 23. 

Stille, A. 59. 



Stokes, Wm., 23. 

Strumous dyscrasia, the, 61. 

Symptomatic fever, 23. 

Syphilis, osteoscopic pains of, 67. 

Syphilitic dyscrasia, the, 63 ; laryngitis, 107 ; 

phthisis, 132. 
Syphilitic general paralysis, 92. 
Syphilitic liver, 185. 
Syphilosis, disseminated, of the cord, 76. 

Tdche cerebrate, the, 53. 

Tape worm, 188. 

Teeth, rheumatic markings on, 68. 

Temperature in fever, 20. 

Temperature, rules for taking, 21, 

Temperature of leading febrile diseases, 22. 

Thread worms, 188. 

Throat in eruptive fevers, 25. 

Thrombosis, cerebral, 75. 

Tongue in fever, 20. 

Tongue in malarious disease, 45. 

Tonsillitis, 112. 

Tricuspid regurgitation, 158. 

Trichinosis, 189. 

Trousseau, A., 26. 

Tubercular dyscrasia, the, 64. 

Tubercular laryngitis, 107. 

Typhlitis, 38. 

Typhoid fever, 32 ; compared with malarial, 

^8 ; with typhoid state, 43 ; compared 

with relapsing fever, 57. 
Typhoid state, the, 41. • 
Typho-malarial fever, 41. 
Typhus fever, 32; compared with epidemic 

meningitis, 54. 

Urinary calculi, 189. 

Urinary organs, diseases of, 191. 

Urine in fever, 22. 

Variola, 25. 
Vertigo, 170. 
Vomited matters, 172. 
Vomiting, 170. 

Warter, J. S., 22. 
Waters, A. T. H., 64. 
Wegscheider, H., 21. 
Westphal, Dr., 85. 
Whittle, W., 75. 
Wilks, S., 26. 
Wood, G. B., 38. 
Wood, H. C, Jr., 79. 
Woodward. J. J., 38. 
Wunderlich, 20, 21. 

Yellow fever, 53. 



,,-=-- -; .-;„ : ss|S 



022 194 830J. 



